THE OFFICIAL PATIENT’S SOURCEBOOK
on
ARRETT S SOPHAGUS J AMES N. P ARKER , M.D. AND P HILIP M. P ARKER , P H .D., E DITORS
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ICON Health Publications ICON Group International, Inc. 4370 La Jolla Village Drive, 4th Floor San Diego, CA 92122 USA Copyright Ó2002 by ICON Group International, Inc. Copyright Ó2002 by ICON Group International, Inc. All rights reserved. This book is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without written permission from the publisher. Printed in the United States of America. Last digit indicates print number: 10 9 8 7 6 4 5 3 2 1
Publisher, Health Care: Tiffany LaRochelle Editor(s): James Parker, M.D., Philip Parker, Ph.D. Publisher’s note: The ideas, procedures, and suggestions contained in this book are not intended as a substitute for consultation with your physician. All matters regarding your health require medical supervision. As new medical or scientific information becomes available from academic and clinical research, recommended treatments and drug therapies may undergo changes. The authors, editors, and publisher have attempted to make the information in this book up to date and accurate in accord with accepted standards at the time of publication. The authors, editors, and publisher are not responsible for errors or omissions or for consequences from application of the book, and make no warranty, expressed or implied, in regard to the contents of this book. Any practice described in this book should be applied by the reader in accordance with professional standards of care used in regard to the unique circumstances that may apply in each situation, in close consultation with a qualified physician. The reader is advised to always check product information (package inserts) for changes and new information regarding dose and contraindications before taking any drug or pharmacological product. Caution is especially urged when using new or infrequently ordered drugs, herbal remedies, vitamins and supplements, alternative therapies, complementary therapies and medicines, and integrative medical treatments. Cataloging-in-Publication Data Parker, James N., 1961Parker, Philip M., 1960The Official Patient’s Sourcebook on Barrett’s Esophagus: A Revised and Updated Directory for the Internet Age/James N. Parker and Philip M. Parker, editors p. cm. Includes bibliographical references, glossary and index. ISBN: 0-597-83274-9 1. Barrett’s Esophagus-Popular works. I. Title.
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Disclaimer This publication is not intended to be used for the diagnosis or treatment of a health problem or as a substitute for consultation with licensed medical professionals. It is sold with the understanding that the publisher, editors, and authors are not engaging in the rendering of medical, psychological, financial, legal, or other professional services. References to any entity, product, service, or source of information that may be contained in this publication should not be considered an endorsement, either direct or implied, by the publisher, editors or authors. ICON Group International, Inc., the editors, or the authors are not responsible for the content of any Web pages nor publications referenced in this publication.
Copyright Notice If a physician wishes to copy limited passages from this sourcebook for patient use, this right is automatically granted without written permission from ICON Group International, Inc. (ICON Group). However, all of ICON Group publications are copyrighted. With exception to the above, copying our publications in whole or in part, for whatever reason, is a violation of copyright laws and can lead to penalties and fines. Should you want to copy tables, graphs or other materials, please contact us to request permission (e-mail:
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Dedication To the healthcare professionals dedicating their time and efforts to the study of Barrett’s esophagus.
Acknowledgements The collective knowledge generated from academic and applied research summarized in various references has been critical in the creation of this sourcebook which is best viewed as a comprehensive compilation and collection of information prepared by various official agencies which directly or indirectly are dedicated to Barrett’s esophagus. All of the Official Patient’s Sourcebooks draw from various agencies and institutions associated with the United States Department of Health and Human Services, and in particular, the Office of the Secretary of Health and Human Services (OS), the Administration for Children and Families (ACF), the Administration on Aging (AOA), the Agency for Healthcare Research and Quality (AHRQ), the Agency for Toxic Substances and Disease Registry (ATSDR), the Centers for Disease Control and Prevention (CDC), the Food and Drug Administration (FDA), the Healthcare Financing Administration (HCFA), the Health Resources and Services Administration (HRSA), the Indian Health Service (IHS), the institutions of the National Institutes of Health (NIH), the Program Support Center (PSC), and the Substance Abuse and Mental Health Services Administration (SAMHSA). In addition to these sources, information gathered from the National Library of Medicine, the United States Patent Office, the European Union, and their related organizations has been invaluable in the creation of this sourcebook. Some of the work represented was financially supported by the Research and Development Committee at INSEAD. This support is gratefully acknowledged. Finally, special thanks are owed to Tiffany LaRochelle for her excellent editorial support.
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About the Editors James N. Parker, M.D. Dr. James N. Parker received his Bachelor of Science degree in Psychobiology from the University of California, Riverside and his M.D. from the University of California, San Diego. In addition to authoring numerous research publications, he has lectured at various academic institutions. Dr. Parker is the medical editor for the Official Patient’s Sourcebook series published by ICON Health Publications.
Philip M. Parker, Ph.D. Philip M. Parker is the Eli Lilly Chair Professor of Innovation, Business and Society at INSEAD (Fontainebleau, France and Singapore). Dr. Parker has also been Professor at the University of California, San Diego and has taught courses at Harvard University, the Hong Kong University of Science and Technology, the Massachusetts Institute of Technology, Stanford University, and UCLA. Dr. Parker is the associate editor for the Official Patient’s Sourcebook series published by ICON Health Publications.
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About ICON Health Publications In addition to Barrett’s esophagus, Official Patient’s Sourcebooks are available for the following related topics: ·
The Official Patient's Sourcebook on Appendicitis
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The Official Patient's Sourcebook on Autoimmune Hepatitis
·
The Official Patient's Sourcebook on Bacteria and Foorborne Illness
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The Official Patient's Sourcebook on Celiac Disease
·
The Official Patient's Sourcebook on Cirrhosis of the Liver
·
The Official Patient's Sourcebook on Constipation
·
The Official Patient's Sourcebook on Crohn Disease
·
The Official Patient's Sourcebook on Cyclic Vomiting Syndrome
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The Official Patient's Sourcebook on Diarrhea
·
The Official Patient's Sourcebook on Diverticular Disease
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The Official Patient's Sourcebook on Fecal Incontinence
·
The Official Patient's Sourcebook on Gallstones
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The Official Patient's Sourcebook on Gas
·
The Official Patient's Sourcebook on Gastritis
·
The Official Patient's Sourcebook on Gastroparesis
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The Official Patient's Sourcebook on Hemolytic Uremic Syndrome
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The Official Patient's Sourcebook on Hemorrhoids
·
The Official Patient's Sourcebook on Hepatitis a
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The Official Patient's Sourcebook on Hepatitis B
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The Official Patient's Sourcebook on Hepatitis C
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The Official Patient's Sourcebook on Hiatal Hernia
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The Official Patient's Sourcebook on Hirschsprung
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The Official Patient's Sourcebook on Indigestion
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The Official Patient's Sourcebook on Inguinal Hernia
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The Official Patient's Sourcebook on Intestinal Pseudo-obstruction
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The Official Patient's Sourcebook on Irritable Bowel Syndrome
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The Official Patient's Sourcebook on Lactose Intolerance
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The Official Patient's Sourcebook on Ménétrier
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The Official Patient's Sourcebook on Pancreatitis
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The Official Patient's Sourcebook on Peptic Ulcer
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The Official Patient's Sourcebook on Porphyria
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The Official Patient's Sourcebook on Primary Biliary Cirrhosis
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The Official Patient's Sourcebook on Primary Sclerosing Cholangitis
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The Official Patient's Sourcebook on Proctitis
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The Official Patient's Sourcebook on Rapid Gastric Emptying
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·
The Official Patient's Sourcebook on Short Bowel Syndrome
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The Official Patient's Sourcebook on Ulcerative Colitis
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The Official Patient's Sourcebook on Whipple Disease
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The Official Patient's Sourcebook on Wilson's Disease
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The Official Patient's Sourcebook on Zollinger-ellison Syndrome
To discover more about ICON Health Publications, simply check with your preferred online booksellers, including Barnes & Noble.com and Amazon.com which currently carry all of our titles. Or, feel free to contact us directly for bulk purchases or institutional discounts: ICON Group International, Inc. 4370 La Jolla Village Drive, Fourth Floor San Diego, CA 92122 USA Fax: 858-546-4341 Web site: www.icongrouponline.com/health
Contents
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Table of Contents INTRODUCTION ................................................................................................................................. 1 Overview ....................................................................................................................................... 1 Organization ................................................................................................................................. 3 Scope.............................................................................................................................................. 3 Moving Forward............................................................................................................................ 4 PART I: THE ESSENTIALS ............................................................................................................. 7 CHAPTER 1. THE ESSENTIALS ON BARRETT’S ESOPHAGUS: GUIDELINES ........................................ 9 Overview ....................................................................................................................................... 9 What Is Barrett’s Esophagus? ..................................................................................................... 11 Additional Information on Barrett’s Esophagus ......................................................................... 12 More Guideline Sources .............................................................................................................. 12 Vocabulary Builder...................................................................................................................... 15 CHAPTER 2. SEEKING GUIDANCE ................................................................................................... 17 Overview ..................................................................................................................................... 17 Associations and Barrett’s Esophagus......................................................................................... 17 Finding More Associations ......................................................................................................... 19 Finding Doctors........................................................................................................................... 20 Selecting Your Doctor ................................................................................................................. 22 Working with Your Doctor ......................................................................................................... 22 Broader Health-Related Resources .............................................................................................. 24 CHAPTER 3. CLINICAL TRIALS AND BARRETT’S ESOPHAGUS ........................................................ 25 Overview ..................................................................................................................................... 25 Recent Trials on Barrett’s Esophagus ......................................................................................... 28 Benefits and Risks........................................................................................................................ 29 Keeping Current on Clinical Trials ............................................................................................. 32 General References....................................................................................................................... 33 PART II: ADDITIONAL RESOURCES AND ADVANCED MATERIAL ........................... 35 CHAPTER 4. STUDIES ON BARRETT’S ESOPHAGUS ......................................................................... 37 Overview ..................................................................................................................................... 37 The Combined Health Information Database .............................................................................. 37 Federally-Funded Research on Barrett’s Esophagus ................................................................... 39 E-Journals: PubMed Central ....................................................................................................... 53 The National Library of Medicine: PubMed................................................................................ 54 Vocabulary Builder...................................................................................................................... 55 CHAPTER 5. BOOKS ON BARRETT’S ESOPHAGUS............................................................................ 59 Overview ..................................................................................................................................... 59 Book Summaries: Online Booksellers .......................................................................................... 59 The National Library of Medicine Book Index............................................................................. 60 Chapters on Barrett’s Esophagus ................................................................................................ 64 General Home References ............................................................................................................ 68 Vocabulary Builder...................................................................................................................... 69 CHAPTER 6. MULTIMEDIA ON BARRETT’S ESOPHAGUS ................................................................. 73 Overview ..................................................................................................................................... 73 Bibliography: Multimedia on Barrett’s Esophagus ..................................................................... 73 Vocabulary Builder...................................................................................................................... 76 CHAPTER 7. PERIODICALS AND NEWS ON BARRETT’S ESOPHAGUS .............................................. 79 Overview ..................................................................................................................................... 79 News Services & Press Releases .................................................................................................. 79 Newsletters on Barrett’s Esophagus............................................................................................ 86
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Contents Newsletter Articles ...................................................................................................................... 86 Academic Periodicals covering Barrett’s Esophagus ................................................................... 87 Vocabulary Builder...................................................................................................................... 88 CHAPTER 8. PHYSICIAN GUIDELINES AND DATABASES ................................................................ 89 Overview ..................................................................................................................................... 89 NIH Guidelines ........................................................................................................................... 89 NIH Databases ............................................................................................................................ 90 Other Commercial Databases ...................................................................................................... 94 The Genome Project and Barrett’s Esophagus............................................................................. 95 Specialized References ................................................................................................................. 99 CHAPTER 9. DISSERTATIONS ON BARRETT’S ESOPHAGUS ........................................................... 101 Overview ................................................................................................................................... 101 Dissertations on Barrett’s Esophagus ....................................................................................... 101 Keeping Current ........................................................................................................................ 102
PART III. APPENDICES .............................................................................................................. 103 APPENDIX A. RESEARCHING YOUR MEDICATIONS ..................................................................... 105 Overview ................................................................................................................................... 105 Your Medications: The Basics ................................................................................................... 106 Learning More about Your Medications ................................................................................... 108 Commercial Databases............................................................................................................... 108 Contraindications and Interactions (Hidden Dangers)............................................................. 110 A Final Warning ....................................................................................................................... 111 General References..................................................................................................................... 111 Vocabulary Builder.................................................................................................................... 112 APPENDIX B. RESEARCHING ALTERNATIVE MEDICINE ............................................................... 113 Overview ................................................................................................................................... 113 What Is CAM? .......................................................................................................................... 113 What Are the Domains of Alternative Medicine? ..................................................................... 114 Can Alternatives Affect My Treatment?................................................................................... 117 Finding CAM References on Barrett’s Esophagus .................................................................... 118 Additional Web Resources......................................................................................................... 119 General References..................................................................................................................... 120 APPENDIX C. RESEARCHING NUTRITION..................................................................................... 123 Overview ................................................................................................................................... 123 Food and Nutrition: General Principles .................................................................................... 124 Finding Studies on Barrett’s Esophagus ................................................................................... 128 Federal Resources on Nutrition................................................................................................. 132 Additional Web Resources......................................................................................................... 132 Vocabulary Builder.................................................................................................................... 133 APPENDIX D. FINDING MEDICAL LIBRARIES ............................................................................... 135 Overview ................................................................................................................................... 135 Preparation ................................................................................................................................ 135 Finding a Local Medical Library ............................................................................................... 136 Medical Libraries Open to the Public ........................................................................................ 136 APPENDIX E. YOUR RIGHTS AND INSURANCE ............................................................................. 143 Overview ................................................................................................................................... 143 Your Rights as a Patient............................................................................................................ 143 Patient Responsibilities ............................................................................................................. 147 Choosing an Insurance Plan...................................................................................................... 148 Medicare and Medicaid ............................................................................................................. 150 NORD’s Medication Assistance Programs............................................................................... 153 Additional Resources................................................................................................................. 154
Contents
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ONLINE GLOSSARIES ............................................................................................................... 155 Online Dictionary Directories................................................................................................... 157 BARRETT’S ESOPHAGUS GLOSSARY .................................................................................. 159 General Dictionaries and Glossaries ......................................................................................... 168 INDEX.............................................................................................................................................. 170
Introduction
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INTRODUCTION Overview Dr. C. Everett Koop, former U.S. Surgeon General, once said, “The best prescription is knowledge.”1 The Agency for Healthcare Research and Quality (AHRQ) of the National Institutes of Health (NIH) echoes this view and recommends that every patient incorporate education into the treatment process. According to the AHRQ: Finding out more about your condition is a good place to start. By contacting groups that support your condition, visiting your local library, and searching on the Internet, you can find good information to help guide your treatment decisions. Some information may be hard to find—especially if you don’t know where to look.2 As the AHRQ mentions, finding the right information is not an obvious task. Though many physicians and public officials had thought that the emergence of the Internet would do much to assist patients in obtaining reliable information, in March 2001 the National Institutes of Health issued the following warning: The number of Web sites offering health-related resources grows every day. Many sites provide valuable information, while others may have information that is unreliable or misleading.3
Quotation from http://www.drkoop.com. The Agency for Healthcare Research and Quality (AHRQ): http://www.ahcpr.gov/consumer/diaginfo.htm. 3 From the NIH, National Cancer Institute (NCI): http://cancertrials.nci.nih.gov/beyond/evaluating.html. 1 2
2
Barrett’s Esophagus
Since the late 1990s, physicians have seen a general increase in patient Internet usage rates. Patients frequently enter their doctor’s offices with printed Web pages of home remedies in the guise of latest medical research. This scenario is so common that doctors often spend more time dispelling misleading information than guiding patients through sound therapies. The Official Patient’s Sourcebook on Barrett’s Esophagus has been created for patients who have decided to make education and research an integral part of the treatment process. The pages that follow will tell you where and how to look for information covering virtually all topics related to Barrett’s esophagus, from the essentials to the most advanced areas of research. The title of this book includes the word “official.” This reflects the fact that the sourcebook draws from public, academic, government, and peerreviewed research. Selected readings from various agencies are reproduced to give you some of the latest official information available to date on Barrett’s esophagus. Given patients’ increasing sophistication in using the Internet, abundant references to reliable Internet-based resources are provided throughout this sourcebook. Where possible, guidance is provided on how to obtain free-ofcharge, primary research results as well as more detailed information via the Internet. E-book and electronic versions of this sourcebook are fully interactive with each of the Internet sites mentioned (clicking on a hyperlink automatically opens your browser to the site indicated). Hard copy users of this sourcebook can type cited Web addresses directly into their browsers to obtain access to the corresponding sites. Since we are working with ICON Health Publications, hard copy Sourcebooks are frequently updated and printed on demand to ensure that the information provided is current. In addition to extensive references accessible via the Internet, every chapter presents a “Vocabulary Builder.” Many health guides offer glossaries of technical or uncommon terms in an appendix. In editing this sourcebook, we have decided to place a smaller glossary within each chapter that covers terms used in that chapter. Given the technical nature of some chapters, you may need to revisit many sections. Building one’s vocabulary of medical terms in such a gradual manner has been shown to improve the learning process. We must emphasize that no sourcebook on Barrett’s esophagus should affirm that a specific diagnostic procedure or treatment discussed in a research study, patent, or doctoral dissertation is “correct” or your best option. This sourcebook is no exception. Each patient is unique. Deciding on
Introduction
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appropriate options is always up to the patient in consultation with their physician and healthcare providers.
Organization This sourcebook is organized into three parts. Part I explores basic techniques to researching Barrett’s esophagus (e.g. finding guidelines on diagnosis, treatments, and prognosis), followed by a number of topics, including information on how to get in touch with organizations, associations, or other patient networks dedicated to Barrett’s esophagus. It also gives you sources of information that can help you find a doctor in your local area specializing in treating Barrett’s esophagus. Collectively, the material presented in Part I is a complete primer on basic research topics for patients with Barrett’s esophagus. Part II moves on to advanced research dedicated to Barrett’s esophagus. Part II is intended for those willing to invest many hours of hard work and study. It is here that we direct you to the latest scientific and applied research on Barrett’s esophagus. When possible, contact names, links via the Internet, and summaries are provided. It is in Part II where the vocabulary process becomes important as authors publishing advanced research frequently use highly specialized language. In general, every attempt is made to recommend “free-to-use” options. Part III provides appendices of useful background reading for all patients with Barrett’s esophagus or related disorders. The appendices are dedicated to more pragmatic issues faced by many patients with Barrett’s esophagus. Accessing materials via medical libraries may be the only option for some readers, so a guide is provided for finding local medical libraries which are open to the public. Part III, therefore, focuses on advice that goes beyond the biological and scientific issues facing patients with Barrett’s esophagus.
Scope While this sourcebook covers Barrett’s esophagus, your doctor, research publications, and specialists may refer to your condition using a variety of terms. Therefore, you should understand that Barrett’s esophagus is often considered a synonym or a condition closely related to the following: ·
Barrett's Esophagus
·
Pediatric Gastroesophageal Reflux
4
Barrett’s Esophagus
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Peptic Esophagitis
·
Reflux Esophagitis
·
Symptomatic Hiatal Hernia
In addition to synonyms and related conditions, physicians may refer to Barrett’s esophagus using certain coding systems. The International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) is the most commonly used system of classification for the world’s illnesses. Your physician may use this coding system as an administrative or tracking tool. The following classification is commonly used for Barrett’s esophagus:4 ·
530.1 esophagitis
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530.81 gastroesophageal reflux dis-ease
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750.6 hiatal hernia
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787.1 heartburn
For the purposes of this sourcebook, we have attempted to be as inclusive as possible, looking for official information for all of the synonyms relevant to Barrett’s esophagus. You may find it useful to refer to synonyms when accessing databases or interacting with healthcare professionals and medical librarians.
Moving Forward Since the 1980s, the world has seen a proliferation of healthcare guides covering most illnesses. Some are written by patients or their family members. These generally take a layperson’s approach to understanding and coping with an illness or disorder. They can be uplifting, encouraging, and highly supportive. Other guides are authored by physicians or other healthcare providers who have a more clinical outlook. Each of these two styles of guide has its purpose and can be quite useful. As editors, we have chosen a third route. We have chosen to expose you to as many sources of official and peer-reviewed information as practical, for the purpose of educating you about basic and advanced knowledge as 4 This list is based on the official version of the World Health Organization’s 9th Revision, International Classification of Diseases (ICD-9). According to the National Technical Information Service, “ICD-9CM extensions, interpretations, modifications, addenda, or errata other than those approved by the U.S. Public Health Service and the Health Care Financing Administration are not to be considered official and should not be utilized. Continuous maintenance of the ICD-9-CM is the responsibility of the federal government.”
Introduction
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recognized by medical science today. You can think of this sourcebook as your personal Internet age reference librarian. Why “Internet age”? All too often, patients diagnosed with Barrett’s esophagus will log on to the Internet, type words into a search engine, and receive several Web site listings which are mostly irrelevant or redundant. These patients are left to wonder where the relevant information is, and how to obtain it. Since only the smallest fraction of information dealing with Barrett’s esophagus is even indexed in search engines, a non-systematic approach often leads to frustration and disappointment. With this sourcebook, we hope to direct you to the information you need that you would not likely find using popular Web directories. Beyond Web listings, in many cases we will reproduce brief summaries or abstracts of available reference materials. These abstracts often contain distilled information on topics of discussion. While we focus on the more scientific aspects of Barrett’s esophagus, there is, of course, the emotional side to consider. Later in the sourcebook, we provide a chapter dedicated to helping you find peer groups and associations that can provide additional support beyond research produced by medical science. We hope that the choices we have made give you the most options available in moving forward. In this way, we wish you the best in your efforts to incorporate this educational approach into your treatment plan. The Editors
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PART I: THE ESSENTIALS
ABOUT PART I Part I has been edited to give you access to what we feel are “the essentials” on Barrett’s esophagus. The essentials of a disease typically include the definition or description of the disease, a discussion of who it affects, the signs or symptoms associated with the disease, tests or diagnostic procedures that might be specific to the disease, and treatments for the disease. Your doctor or healthcare provider may have already explained the essentials of Barrett’s esophagus to you or even given you a pamphlet or brochure describing Barrett’s esophagus. Now you are searching for more in-depth information. As editors, we have decided, nevertheless, to include a discussion on where to find essential information that can complement what your doctor has already told you. In this section we recommend a process, not a particular Web site or reference book. The process ensures that, as you search the Web, you gain background information in such a way as to maximize your understanding.
Guidelines
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CHAPTER 1. THE ESSENTIALS ON BARRETT’S ESOPHAGUS: GUIDELINES Overview Official agencies, as well as federally-funded institutions supported by national grants, frequently publish a variety of guidelines on Barrett’s esophagus. These are typically called “Fact Sheets” or “Guidelines.” They can take the form of a brochure, information kit, pamphlet, or flyer. Often they are only a few pages in length. The great advantage of guidelines over other sources is that they are often written with the patient in mind. Since new guidelines on Barrett’s esophagus can appear at any moment and be published by a number of sources, the best approach to finding guidelines is to systematically scan the Internet-based services that post them.
The National Institutes of Health (NIH)5 The National Institutes of Health (NIH) is the first place to search for relatively current patient guidelines and fact sheets on Barrett’s esophagus. Originally founded in 1887, the NIH is one of the world’s foremost medical research centers and the federal focal point for medical research in the United States. At any given time, the NIH supports some 35,000 research grants at universities, medical schools, and other research and training institutions, both nationally and internationally. The rosters of those who have conducted research or who have received NIH support over the years include the world’s most illustrious scientists and physicians. Among them are 97 scientists who have won the Nobel Prize for achievement in medicine.
5
Adapted from the NIH: http://www.nih.gov/about/NIHoverview.html.
10 Barrett’s Esophagus
There is no guarantee that any one Institute will have a guideline on a specific disease, though the National Institutes of Health collectively publish over 600 guidelines for both common and rare diseases. The best way to access NIH guidelines is via the Internet. Although the NIH is organized into many different Institutes and Offices, the following is a list of key Web sites where you are most likely to find NIH clinical guidelines and publications dealing with Barrett’s esophagus and associated conditions: ·
Office of the Director (OD); guidelines consolidated across agencies available at http://www.nih.gov/health/consumer/conkey.htm
·
National Library of Medicine (NLM); extensive encyclopedia (A.D.A.M., Inc.) with guidelines available at http://www.nlm.nih.gov/medlineplus/healthtopics.html
·
National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK); guidelines available at http://www.niddk.nih.gov/health/health.htm
Among these, the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) is particularly noteworthy. The NIDDK’s mission is to conduct and support research on many of the most serious diseases affecting public health.6 The Institute supports much of the clinical research on the diseases of internal medicine and related subspecialty fields as well as many basic science disciplines. The NIDDK’s Division of Intramural Research encompasses the broad spectrum of metabolic diseases such as diabetes, inborn errors of metabolism, endocrine disorders, mineral metabolism, digestive diseases, nutrition, urology and renal disease, and hematology. Basic research studies include biochemistry, nutrition, pathology, histochemistry, chemistry, physical, chemical, and molecular biology, pharmacology, and toxicology. NIDDK extramural research is organized into divisions of program areas: ·
Division of Diabetes, Endocrinology, and Metabolic Diseases
·
Division of Digestive Diseases and Nutrition
·
Division of Kidney, Urologic, and Hematologic Diseases
The Division of Extramural Activities provides administrative support and overall coordination. A fifth division, the Division of Nutrition Research Coordination, coordinates government nutrition research efforts. The Institute supports basic and clinical research through investigator-initiated This paragraph has been adapted from the NIDDK: http://www.niddk.nih.gov/welcome/mission.htm. “Adapted” signifies that a passage is reproduced exactly or slightly edited for this book. 6
Guidelines 11
grants, program project and center grants, and career development and training awards. The Institute also supports research and development projects and large-scale clinical trials through contracts. The following patient guideline was recently published by the NIDDK on Barrett’s esophagus.
What Is Barrett’s Esophagus?7 Barrett’s esophagus is a condition that develops in some people who have chronic gastroesophageal reflux disease (GERD) or inflammation of the esophagus (esophagitis). In Barrett’s esophagus, the normal cells that line the esophagus, called squamous cells, turn into a type of cell not usually found in humans, called specialized columnar cells. Damage to the lining of the esophagus--for example, by acid reflux from GERD--causes these abnormal changes. People who have had regular or daily heartburn for more than 5 years may be at risk for Barrett’s esophagus and should discuss the possibility with their doctor. Symptoms include waking during the night because of heartburn pain, vomiting, blood in vomit or stool, and difficulty swallowing. Some people do not have symptoms. Diagnosis involves an endoscopy to look at the lining of the esophagus and a biopsy to examine a sample of tissue. To do an endoscopy, the doctor gently guides a long, thin tube called an endoscope through the mouth and into the esophagus. The scope contains instruments that allow the doctor to see the lining of the esophagus and to remove a small tissue sample, called a biopsy. The biopsy will be examined in a lab to see whether the normal squamous cells have been replaced with columnar cells. Once the cells in the lining of the esophagus have turned into columnar cells, they will not revert back to normal. In other words, at this time, there is no cure for Barrett’s esophagus. The goal of treatment is to prevent further damage by stopping any acid reflux from the stomach. Medications that are helpful include H2 receptor antagonists (or H2 blockers) and proton pump inhibitors, which reduce the amount of acid produced by the stomach. Examples of H2 blockers are cimetidine, ranitidine, and famotidine; the drugs omeprazole and lansoprazole are proton pump inhibitors. If these medications do not work, surgery to remove damaged tissue or a section of Adapted from The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK): http://www.niddk.nih.gov/health/digest/summary/barretts/barretts.htm. 7
12 Barrett’s Esophagus
the esophagus itself may be necessary. Fundoplication is the name of the surgery to remove part of the esophagus and attach the stomach to the remaining section. Sometimes the damaged lining of the esophagus becomes thick and hardened, causing strictures, or narrowing of the esophagus. Strictures can interfere with eating and drinking by preventing food and liquid from reaching the stomach. Strictures are treated by dilation, in which an instrument gently stretches the strictures and expands the opening in the esophagus. About 5 to 10 percent of people with Barrett’s develop cancer of the esophagus. Because of the cancer risk, people with Barrett’s esophagus are screened for esophageal cancer regularly.
Additional Information on Barrett’s Esophagus The National Digestive Diseases Information Clearinghouse collects resource information on digestive diseases for the Combined Health Information Database (CHID), a database produced by health-related agencies of the Federal Government. This database provides titles, abstracts, and availability information for health information and health education resources. To provide you with the most up-to-date resources, information specialists at the clearinghouse created an automatic CHID search. To obtain this information, you may view the results of the automatic search on Barrett’s esophagus. Or, if you wish to perform your own search of the database, you may access the CHID Onlineweb site and search CHID yourself (http://chid.nih.gov/).
More Guideline Sources The guideline above on Barrett’s esophagus is only one example of the kind of material that you can find online and free of charge. The remainder of this chapter will direct you to other sources which either publish or can help you find additional guidelines on topics related to Barrett’s esophagus. Many of the guidelines listed below address topics that may be of particular relevance to your specific situation or of special interest to only some patients with Barrett’s esophagus. Due to space limitations these sources are listed in a concise manner. Do not hesitate to consult the following sources by either
Guidelines 13
using the Internet hyperlink provided, or, in cases where the contact information is provided, contacting the publisher or author directly.
Topic Pages: MEDLINEplus For patients wishing to go beyond guidelines published by specific Institutes of the NIH, the National Library of Medicine has created a vast and patientoriented healthcare information portal called MEDLINEplus. Within this Internet-based system are “health topic pages.” You can think of a health topic page as a guide to patient guides. To access this system, log on to http://www.nlm.nih.gov/medlineplus/healthtopics.html. From there you can either search using the alphabetical index or browse by broad topic areas. If you do not find topics of interest when browsing health topic pages, then you can choose to use the advanced search utility of MEDLINEplus at http://www.nlm.nih.gov/medlineplus/advancedsearch.html. This utility is similar to the NIH Search Utility, with the exception that it only includes material linked within the MEDLINEplus system (mostly patient-oriented information). It also has the disadvantage of generating unstructured results. We recommend, therefore, that you use this method only if you have a very targeted search.
The National Guideline Clearinghouse™ The National Guideline Clearinghouse™ offers hundreds of evidence-based clinical practice guidelines published in the United States and other countries. You can search their site located at http://www.guideline.gov by using the keyword “Barrett’s esophagus” or synonyms. The following was recently posted: ·
Surgical treatment of reflux esophagitis. Source: Society for Surgery of the Alimentary Tract, Inc..; 1998 June 3 (revised 2000 Jan); 4 pages http://www.guideline.gov/FRAMESETS/guideline_fs.asp?guideline=00 1396&sSearch_string=Barrett%27s+esophagus
14 Barrett’s Esophagus
Healthfinder™ Healthfinder™ is an additional source sponsored by the U.S. Department of Health and Human Services which offers links to hundreds of other sites that contain healthcare information. This Web site is located at http://www.healthfinder.gov. Again, keyword searches can be used to find guidelines. The following was recently found in this database: ·
Barrett's Esophagus Summary: Describes the condition of Barrett's esophagus and its symptoms, diagnosis, and treatment. Source: National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health http://www.healthfinder.gov/scripts/recordpass.asp?RecordType=0&R ecordID=6493 The NIH Search Utility
After browsing the references listed at the beginning of this chapter, you may want to explore the NIH Search Utility. This allows you to search for documents on over 100 selected Web sites that comprise the NIH-WEBSPACE. Each of these servers is “crawled” and indexed on an ongoing basis. Your search will produce a list of various documents, all of which will relate in some way to Barrett’s esophagus. The drawbacks of this approach are that the information is not organized by theme and that the references are often a mix of information for professionals and patients. Nevertheless, a large number of the listed Web sites provide useful background information. We can only recommend this route, therefore, for relatively rare or specific disorders, or when using highly targeted searches. To use the NIH search utility, visit the following Web page: http://search.nih.gov/index.html.
Guidelines 15
Additional Web Sources A number of Web sites that often link to government sites are available to the public. These can also point you in the direction of essential information. The following is a representative sample: ·
AOL: http://search.aol.com/cat.adp?id=168&layer=&from=subcats
·
drkoop.comÒ: http://www.drkoop.com/conditions/ency/index.html
·
Family Village: http://www.familyvillage.wisc.edu/specific.htm
·
Google: http://directory.google.com/Top/Health/Conditions_and_Diseases/
·
Med Help International: http://www.medhelp.org/HealthTopics/A.html
·
Open Directory Project: http://dmoz.org/Health/Conditions_and_Diseases/
·
Yahoo.com: http://dir.yahoo.com/Health/Diseases_and_Conditions/
·
WebMDÒHealth: http://my.webmd.com/health_topics
Vocabulary Builder The material in this chapter may have contained a number of unfamiliar words. The following Vocabulary Builder introduces you to terms used in this chapter that have not been covered in the previous chapter: Alimentary: Pertaining to food or nutritive material, or to the organs of digestion. [EU] Biopsy: The removal and examination, usually microscopic, of tissue from the living body, performed to establish precise diagnosis. [EU] Chronic: Persisting over a long period of time. [EU] Cimetidine: A histamine congener, it competitively inhibits histamine binding to H2 receptors. Cimetidine has a range of pharmacological actions. It inhibits gastric acid secretion, as well as pepsin and gastrin output. It also blocks the activity of cytochrome P-450. [NIH] Endocrinology: A subspecialty of internal medicine concerned with the metabolism, physiology, and disorders of the endocrine system. [NIH] Endoscopy: Visual inspection of any cavity of the body by means of an endoscope. [EU] Esophagitis: Inflammation, acute or chronic, of the esophagus caused by bacteria, chemicals, or trauma. [NIH]
16 Barrett’s Esophagus
Famotidine: A competitive histamine H2-receptor antagonist. Its main pharmacodynamic effect is the inhibition of gastric secretion. [NIH] Heartburn: Substernal pain or burning sensation, usually associated with regurgitation of gastric juice into the esophagus. [NIH] Hematology: A subspecialty of internal medicine concerned with morphology, physiology, and pathology of the blood and blood-forming tissues. [NIH] Inflammation: A pathological process characterized by injury or destruction of tissues caused by a variety of cytologic and chemical reactions. It is usually manifested by typical signs of pain, heat, redness, swelling, and loss of function. [NIH] Molecular: Of, pertaining to, or composed of molecules : a very small mass of matter. [EU] Receptor: 1. a molecular structure within a cell or on the surface characterized by (1) selective binding of a specific substance and (2) a specific physiologic effect that accompanies the binding, e.g., cell-surface receptors for peptide hormones, neurotransmitters, antigens, complement fragments, and immunoglobulins and cytoplasmic receptors for steroid hormones. 2. a sensory nerve terminal that responds to stimuli of various kinds. [EU] Reflux: A backward or return flow. [EU] Spectrum: A charted band of wavelengths of electromagnetic vibrations obtained by refraction and diffraction. By extension, a measurable range of activity, such as the range of bacteria affected by an antibiotic (antibacterial s.) or the complete range of manifestations of a disease. [EU] Squamous: Scaly, or platelike. [EU] Stomach: An organ of digestion situated in the left upper quadrant of the abdomen between the termination of the esophagus and the beginning of the duodenum. [NIH] Toxicology: The science concerned with the detection, chemical composition, and pharmacologic action of toxic substances or poisons and the treatment and prevention of toxic manifestations. [NIH] Urology: A surgical specialty concerned with the study, diagnosis, and treatment of diseases of the urinary tract in both sexes and the genital tract in the male. It includes the specialty of andrology which addresses both male genital diseases and male infertility. [NIH]
Seeking Guidance 17
CHAPTER 2. SEEKING GUIDANCE Overview Some patients are comforted by the knowledge that a number of organizations dedicate their resources to helping people with Barrett’s esophagus. These associations can become invaluable sources of information and advice. Many associations offer aftercare support, financial assistance, and other important services. Furthermore, healthcare research has shown that support groups often help people to better cope with their conditions.8 In addition to support groups, your physician can be a valuable source of guidance and support. Therefore, finding a physician that can work with your unique situation is a very important aspect of your care. In this chapter, we direct you to resources that can help you find patient organizations and medical specialists. We begin by describing how to find associations and peer groups that can help you better understand and cope with Barrett’s esophagus. The chapter ends with a discussion on how to find a doctor that is right for you.
Associations and Barrett’s Esophagus As mentioned by the Agency for Healthcare Research and Quality, sometimes the emotional side of an illness can be as taxing as the physical side.9 You may have fears or feel overwhelmed by your situation. Everyone has different ways of dealing with disease or physical injury. Your attitude, your expectations, and how well you cope with your condition can all Churches, synagogues, and other houses of worship might also have groups that can offer you the social support you need. 9 This section has been adapted from http://www.ahcpr.gov/consumer/diaginf5.htm. 8
18 Barrett’s Esophagus
influence your well-being. This is true for both minor conditions and serious illnesses. For example, a study on female breast cancer survivors revealed that women who participated in support groups lived longer and experienced better quality of life when compared with women who did not participate. In the support group, women learned coping skills and had the opportunity to share their feelings with other women in the same situation. In addition to associations or groups that your doctor might recommend, we suggest that you consider the following list (if there is a fee for an association, you may want to check with your insurance provider to find out if the cost will be covered): ·
Pediatric/Adolescent Gastroesophageal Reflux Association, Inc Address: Pediatric/Adolescent Gastroesophageal Reflux Association, Inc. P.O. Box 1153, Germantown, MD 20875-1153 Telephone: (301) 601-9541 Email:
[email protected] Web Site: http://www.reflux.org Background: The Pediatric/Adolescent Gastroesophageal Reflux Association, Inc. (PAGER) is a non-profit, parent-led organization dedicated to offering support and information to parents of children with gastroesophageal reflux and related disorders. Gastroesophageal reflux is the inappropriate backward flow of stomach contents into the esophagus. A diagnosis of gastroesophageal reflux (GER) is given only when the 'backwashing' is causing problems. A child is said to have Gastroesophageal Reflux Disease (GERD) if the backwashing has caused damage, such as failure to gain weight; respiratory symptoms including asthma, choking, and repeated infections due to aspiration; and/or esophageal irritation and scarring. Founded in 1992, PAGER disseminates information on pediatric gastroesophageal reflux and related disorders; provides support and education to individuals and families affected by GER; and promotes public awareness of the condition. PAGER publishes a monthly newsletter containing stories from families, research updates, practical ideas for affected individuals and families, and a list of new members. Also available is medical literature on GER and related disorders with descriptions of tests, procedures, medications, and parent-tested home care techniques. Program activities include monthly support and information meetings.
Seeking Guidance 19
Finding More Associations There are a number of directories that list additional medical associations that you may find useful. While not all of these directories will provide different information than what is listed above, by consulting all of them, you will have nearly exhausted all sources for patient associations.
The National Health Information Center (NHIC) The National Health Information Center (NHIC) offers a free referral service to help people find organizations that provide information about Barrett’s esophagus. For more information, see the NHIC’s Web site at http://www.health.gov/NHIC/ or contact an information specialist by calling 1-800-336-4797.
DIRLINE A comprehensive source of information on associations is the DIRLINE database maintained by the National Library of Medicine. The database comprises some 10,000 records of organizations, research centers, and government institutes and associations which primarily focus on health and biomedicine. DIRLINE is available via the Internet at the following Web site: http://dirline.nlm.nih.gov/. Simply type in “Barrett’s esophagus” (or a synonym) or the name of a topic, and the site will list information contained in the database on all relevant organizations.
The Combined Health Information Database Another comprehensive source of information on healthcare associations is the Combined Health Information Database. Using the “Detailed Search” option, you will need to limit your search to “Organizations” and “Barrett’s esophagus”. Type the following hyperlink into your Web browser: http://chid.nih.gov/detail/detail.html. To find associations, use the drop boxes at the bottom of the search page where “You may refine your search by.” For publication date, select “All Years.” Then, select your preferred language and the format option “Organization Resource Sheet.” By making these selections and typing in “Barrett’s esophagus” (or synonyms) into the “For these words:” box, you will only receive results on organizations dealing with Barrett’s esophagus. You should check back periodically with this database since it is updated every 3 months.
20 Barrett’s Esophagus
The National Organization for Rare Disorders, Inc. The National Organization for Rare Disorders, Inc. has prepared a Web site that provides, at no charge, lists of associations organized by specific diseases. You can access this database at the following Web site: http://www.rarediseases.org/cgi-bin/nord/searchpage. Select the option called “Organizational Database (ODB)” and type “Barrett’s esophagus” (or a synonym) in the search box.
Online Support Groups In addition to support groups, commercial Internet service providers offer forums and chat rooms for people with different illnesses and conditions. WebMDÒ, for example, offers such a service at their Web site: http://boards.webmd.com/roundtable. These online self-help communities can help you connect with a network of people whose concerns are similar to yours. Online support groups are places where people can talk informally. If you read about a novel approach, consult with your doctor or other healthcare providers, as the treatments or discoveries you hear about may not be scientifically proven to be safe and effective.
Finding Doctors One of the most important aspects of your treatment will be the relationship between you and your doctor or specialist. All patients with Barrett’s esophagus must go through the process of selecting a physician. While this process will vary from person to person, the Agency for Healthcare Research and Quality makes a number of suggestions, including the following:10 ·
If you are in a managed care plan, check the plan’s list of doctors first.
·
Ask doctors or other health professionals who work with doctors, such as hospital nurses, for referrals.
·
Call a hospital’s doctor referral service, but keep in mind that these services usually refer you to doctors on staff at that particular hospital. The services do not have information on the quality of care that these doctors provide.
10
This section is adapted from the AHRQ: www.ahrq.gov/consumer/qntascii/qntdr.htm.
Seeking Guidance 21
·
Some local medical societies offer lists of member doctors. Again, these lists do not have information on the quality of care that these doctors provide.
Additional steps you can take to locate doctors include the following: ·
Check with the associations listed earlier in this chapter.
·
Information on doctors in some states is available on the Internet at http://www.docboard.org. This Web site is run by “Administrators in Medicine,” a group of state medical board directors.
·
The American Board of Medical Specialties can tell you if your doctor is board certified. “Certified” means that the doctor has completed a training program in a specialty and has passed an exam, or “board,” to assess his or her knowledge, skills, and experience to provide quality patient care in that specialty. Primary care doctors may also be certified as specialists. The AMBS Web site is located at http://www.abms.org/newsearch.asp.11 You can also contact the ABMS by phone at 1-866-ASK-ABMS.
·
You can call the American Medical Association (AMA) at 800-665-2882 for information on training, specialties, and board certification for many licensed doctors in the United States. This information also can be found in “Physician Select” at the AMA’s Web site: http://www.amaassn.org/aps/amahg.htm.
If the previous sources did not meet your needs, you may want to log on to the Web site of the National Organization for Rare Disorders (NORD) at http://www.rarediseases.org/. NORD maintains a database of doctors with expertise in various rare diseases. The Metabolic Information Network (MIN), 800-945-2188, also maintains a database of physicians with expertise in various metabolic diseases.
While board certification is a good measure of a doctor’s knowledge, it is possible to receive quality care from doctors who are not board certified. 11
22 Barrett’s Esophagus
Selecting Your Doctor12 When you have compiled a list of prospective doctors, call each of their offices. First, ask if the doctor accepts your health insurance plan and if he or she is taking new patients. If the doctor is not covered by your plan, ask yourself if you are prepared to pay the extra costs. The next step is to schedule a visit with your chosen physician. During the first visit you will have the opportunity to evaluate your doctor and to find out if you feel comfortable with him or her. Ask yourself, did the doctor: ·
Give me a chance to ask questions about Barrett’s esophagus?
·
Really listen to my questions?
·
Answer in terms I understood?
·
Show respect for me?
·
Ask me questions?
·
Make me feel comfortable?
·
Address the health problem(s) I came with?
·
Ask me my preferences about different kinds of treatments for Barrett’s esophagus?
·
Spend enough time with me?
Trust your instincts when deciding if the doctor is right for you. But remember, it might take time for the relationship to develop. It takes more than one visit for you and your doctor to get to know each other.
Working with Your Doctor13 Research has shown that patients who have good relationships with their doctors tend to be more satisfied with their care and have better results. Here are some tips to help you and your doctor become partners: ·
You know important things about your symptoms and your health history. Tell your doctor what you think he or she needs to know.
·
It is important to tell your doctor personal information, even if it makes you feel embarrassed or uncomfortable.
12 This
section has been adapted from the AHRQ: www.ahrq.gov/consumer/qntascii/qntdr.htm. 13 This section has been adapted from the AHRQ: www.ahrq.gov/consumer/qntascii/qntdr.htm.
Seeking Guidance 23
·
Bring a “health history” list with you (and keep it up to date).
·
Always bring any medications you are currently taking with you to the appointment, or you can bring a list of your medications including dosage and frequency information. Talk about any allergies or reactions you have had to your medications.
·
Tell your doctor about any natural or alternative medicines you are taking.
·
Bring other medical information, such as x-ray films, test results, and medical records.
·
Ask questions. If you don’t, your doctor will assume that you understood everything that was said.
·
Write down your questions before your visit. List the most important ones first to make sure that they are addressed.
·
Consider bringing a friend with you to the appointment to help you ask questions. This person can also help you understand and/or remember the answers.
·
Ask your doctor to draw pictures if you think that this would help you understand.
·
Take notes. Some doctors do not mind if you bring a tape recorder to help you remember things, but always ask first.
·
Let your doctor know if you need more time. If there is not time that day, perhaps you can speak to a nurse or physician assistant on staff or schedule a telephone appointment.
·
Take information home. Ask for written instructions. Your doctor may also have brochures and audio and videotapes that can help you.
·
After leaving the doctor’s office, take responsibility for your care. If you have questions, call. If your symptoms get worse or if you have problems with your medication, call. If you had tests and do not hear from your doctor, call for your test results. If your doctor recommended that you have certain tests, schedule an appointment to get them done. If your doctor said you should see an additional specialist, make an appointment.
By following these steps, you will enhance the relationship you will have with your physician.
24 Barrett’s Esophagus
Broader Health-Related Resources In addition to the references above, the NIH has set up guidance Web sites that can help patients find healthcare professionals. These include:14 ·
Caregivers: http://www.nlm.nih.gov/medlineplus/caregivers.html
·
Choosing a Doctor or Healthcare Service: http://www.nlm.nih.gov/medlineplus/choosingadoctororhealthcareserv ice.html
·
Hospitals and Health Facilities: http://www.nlm.nih.gov/medlineplus/healthfacilities.html
You can access this information at: http://www.nlm.nih.gov/medlineplus/healthsystem.html.
14
Clinical Trials 25
CHAPTER 3. ESOPHAGUS
CLINICAL
TRIALS
AND
BARRETT’S
Overview Very few medical conditions have a single treatment. The basic treatment guidelines that your physician has discussed with you, or those that you have found using the techniques discussed in Chapter 1, may provide you with all that you will require. For some patients, current treatments can be enhanced with new or innovative techniques currently under investigation. In this chapter, we will describe how clinical trials work and show you how to keep informed of trials concerning Barrett’s esophagus.
What Is a Clinical Trial?15 Clinical trials involve the participation of people in medical research. Most medical research begins with studies in test tubes and on animals. Treatments that show promise in these early studies may then be tried with people. The only sure way to find out whether a new treatment is safe, effective, and better than other treatments for Barrett’s esophagus is to try it on patients in a clinical trial.
The discussion in this chapter has been adapted from the NIH and the NEI: www.nei.nih.gov/netrials/ctivr.htm.
15
26 Barrett’s Esophagus
What Kinds of Clinical Trials Are There? Clinical trials are carried out in three phases: ·
Phase I. Researchers first conduct Phase I trials with small numbers of patients and healthy volunteers. If the new treatment is a medication, researchers also try to determine how much of it can be given safely.
·
Phase II. Researchers conduct Phase II trials in small numbers of patients to find out the effect of a new treatment on Barrett’s esophagus.
·
Phase III. Finally, researchers conduct Phase III trials to find out how new treatments for Barrett’s esophagus compare with standard treatments already being used. Phase III trials also help to determine if new treatments have any side effects. These trials--which may involve hundreds, perhaps thousands, of people--can also compare new treatments with no treatment. How Is a Clinical Trial Conducted?
Various organizations support clinical trials at medical centers, hospitals, universities, and doctors’ offices across the United States. The “principal investigator” is the researcher in charge of the study at each facility participating in the clinical trial. Most clinical trial researchers are medical doctors, academic researchers, and specialists. The “clinic coordinator” knows all about how the study works and makes all the arrangements for your visits. All doctors and researchers who take part in the study on Barrett’s esophagus carefully follow a detailed treatment plan called a protocol. This plan fully explains how the doctors will treat you in the study. The “protocol” ensures that all patients are treated in the same way, no matter where they receive care. Clinical trials are controlled. This means that researchers compare the effects of the new treatment with those of the standard treatment. In some cases, when no standard treatment exists, the new treatment is compared with no treatment. Patients who receive the new treatment are in the treatment group. Patients who receive a standard treatment or no treatment are in the “control” group. In some clinical trials, patients in the treatment group get a new medication while those in the control group get a placebo. A placebo is a harmless substance, a “dummy” pill, that has no effect on Barrett’s esophagus. In other clinical trials, where a new surgery or device (not a medicine) is being tested, patients in the control group may receive a “sham
Clinical Trials 27
treatment.” This treatment, like a placebo, has no effect on Barrett’s esophagus and does not harm patients. Researchers assign patients “randomly” to the treatment or control group. This is like flipping a coin to decide which patients are in each group. If you choose to participate in a clinical trial, you will not know which group you will be appointed to. The chance of any patient getting the new treatment is about 50 percent. You cannot request to receive the new treatment instead of the placebo or sham treatment. Often, you will not know until the study is over whether you have been in the treatment group or the control group. This is called a “masked” study. In some trials, neither doctors nor patients know who is getting which treatment. This is called a “double masked” study. These types of trials help to ensure that the perceptions of the patients or doctors will not affect the study results. Natural History Studies Unlike clinical trials in which patient volunteers may receive new treatments, natural history studies provide important information to researchers on how Barrett’s esophagus develops over time. A natural history study follows patient volunteers to see how factors such as age, sex, race, or family history might make some people more or less at risk for Barrett’s esophagus. A natural history study may also tell researchers if diet, lifestyle, or occupation affects how a disease or disorder develops and progresses. Results from these studies provide information that helps answer questions such as: How fast will a disease or disorder usually progress? How bad will the condition become? Will treatment be needed? What Is Expected of Patients in a Clinical Trial? Not everyone can take part in a clinical trial for a specific disease or disorder. Each study enrolls patients with certain features or eligibility criteria. These criteria may include the type and stage of disease or disorder, as well as, the age and previous treatment history of the patient. You or your doctor can contact the sponsoring organization to find out more about specific clinical trials and their eligibility criteria. If you are interested in joining a clinical trial, your doctor must contact one of the trial’s investigators and provide details about your diagnosis and medical history. If you participate in a clinical trial, you may be required to have a number of medical tests. You may also need to take medications and/or undergo
28 Barrett’s Esophagus
surgery. Depending upon the treatment and the examination procedure, you may be required to receive inpatient hospital care. Or, you may have to return to the medical facility for follow-up examinations. These exams help find out how well the treatment is working. Follow-up studies can take months or years. However, the success of the clinical trial often depends on learning what happens to patients over a long period of time. Only patients who continue to return for follow-up examinations can provide this important long-term information.
Recent Trials on Barrett’s Esophagus The National Institutes of Health and other organizations sponsor trials on various diseases and disorders. Because funding for research goes to the medical areas that show promising research opportunities, it is not possible for the NIH or others to sponsor clinical trials for every disease and disorder at all times. The following lists recent trials dedicated to Barrett’s esophagus.16 If the trial listed by the NIH is still recruiting, you may be eligible. If it is no longer recruiting or has been completed, then you can contact the sponsors to learn more about the study and, if published, the results. Further information on the trial is available at the Web site indicated. Please note that some trials may no longer be recruiting patients or are otherwise closed. Before contacting sponsors of a clinical trial, consult with your physician who can help you determine if you might benefit from participation. ·
Celecoxib to Prevent Cancer in Patients With Barrett's Esophagus Condition(s): prevention of esophageal cancer; esophageal cancer Study Status: This study is currently recruiting patients. Sponsor(s): National Cancer Institute (NCI); Sidney Kimmel Cancer Center Purpose - Excerpt: Rationale: Chemoprevention therapy is the use of certain drugs to try to prevent the development or recurrence of cancer. Celecoxib may be effective in preventing cancer in patients with Barrett's esophagus. Purpose: Randomized phase II trial to study the effectiveness of celecoxib in preventing cancer in patients who have Barrett's esophagus. Phase(s): Phase II Study Type: Prevention Contact(s): see Web site below
16
These are listed at www.ClinicalTrials.gov.
Clinical Trials 29
Web Site: http://clinicaltrials.gov/ct/gui/show/NCT00005878;jsessionid=956360E 5B65971D259F83176A88453F0 ·
Photodynamic Therapy in Treating Patients With Early Esophageal Cancer Condition(s): stage 0 esophageal cancer Study Status: This study is currently recruiting patients. Sponsor(s): National Cancer Institute (NCI); Roswell Park Cancer Institute Purpose - Excerpt: RATIONALE: Photodynamic therapy uses light and drugs that make cancer cells more sensitive to light to kill tumor cells. This may be an effective treatment for esophageal cancer. PURPOSE: Phase II trial to study the effectiveness of photodynamic therapy in treating patients with Barrett's esophagus who have in situ esophageal cancer. Phase(s): Phase II Study Type: Treatment Contact(s): New York; Roswell Park Cancer Institute, Buffalo, New York, 14263-0001, United States; Recruiting; Hector Nava 716-845-5915. Study chairs or principal investigators: Hector Nava, Study Chair; Roswell Park Cancer Institute Web Site: http://clinicaltrials.gov/ct/gui/show/NCT00002935;jsessionid=956360E 5B65971D259F83176A88453F0
Benefits and Risks17 What Are the Benefits of Participating in a Clinical Trial? If you are interested in a clinical trial, it is important to realize that your participation can bring many benefits to you and society at large: ·
A new treatment could be more effective than the current treatment for Barrett’s esophagus. Although only half of the participants in a clinical
This section has been adapted from ClinicalTrials.gov, a service of the National Institutes of Health: http://www.clinicaltrials.gov/ct/gui/c/a1r/info/whatis?JServSessionIdzone_ct=9jmun6f291. 17
30 Barrett’s Esophagus
trial receive the experimental treatment, if the new treatment is proved to be more effective and safer than the current treatment, then those patients who did not receive the new treatment during the clinical trial may be among the first to benefit from it when the study is over. ·
If the treatment is effective, then it may improve health or prevent diseases or disorders.
·
Clinical trial patients receive the highest quality of medical care. Experts watch them closely during the study and may continue to follow them after the study is over.
·
People who take part in trials contribute to scientific discoveries that may help other people with Barrett’s esophagus. In cases where certain diseases or disorders run in families, your participation may lead to better care or prevention for your family members. The Informed Consent
Once you agree to take part in a clinical trial, you will be asked to sign an “informed consent.” This document explains a clinical trial’s risks and benefits, the researcher’s expectations of you, and your rights as a patient. What Are the Risks? Clinical trials may involve risks as well as benefits. Whether or not a new treatment will work cannot be known ahead of time. There is always a chance that a new treatment may not work better than a standard treatment. There is also the possibility that it may be harmful. The treatment you receive may cause side effects that are serious enough to require medical attention.
How Is Patient Safety Protected? Clinical trials can raise fears of the unknown. Understanding the safeguards that protect patients can ease some of these fears. Before a clinical trial begins, researchers must get approval from their hospital’s Institutional Review Board (IRB), an advisory group that makes sure a clinical trial is designed to protect patient safety. During a clinical trial, doctors will closely watch you to see if the treatment is working and if you are experiencing any side effects. All the results are carefully recorded and reviewed. In many cases, experts from the Data and Safety Monitoring Committee carefully
Clinical Trials 31
monitor each clinical trial and can recommend that a study be stopped at any time. You will only be asked to take part in a clinical trial as a volunteer giving informed consent. What Are a Patient’s Rights in a Clinical Trial? If you are eligible for a clinical trial, you will be given information to help you decide whether or not you want to participate. As a patient, you have the right to: ·
Information on all known risks and benefits of the treatments in the study.
·
Know how the researchers plan to carry out the study, for how long, and where.
·
Know what is expected of you.
·
Know any costs involved for you or your insurance provider.
·
Know before any of your medical or personal information is shared with other researchers involved in the clinical trial.
·
Talk openly with doctors and ask any questions.
After you join a clinical trial, you have the right to: ·
Leave the study at any time. Participation is strictly voluntary. However, you should not enroll if you do not plan to complete the study.
·
Receive any new information about the new treatment.
·
Continue to ask questions and get answers.
·
Maintain your privacy. Your name will not appear in any reports based on the study.
·
Know whether you participated in the treatment group or the control group (once the study has been completed). What about Costs?
In some clinical trials, the research facility pays for treatment costs and other associated expenses. You or your insurance provider may have to pay for costs that are considered standard care. These things may include inpatient hospital care, laboratory and other tests, and medical procedures. You also may need to pay for travel between your home and the clinic. You should
32 Barrett’s Esophagus
find out about costs before committing to participation in the trial. If you have health insurance, find out exactly what it will cover. If you don’t have health insurance, or if your insurance company will not cover your costs, talk to the clinic staff about other options for covering the cost of your care. What Should You Ask before Deciding to Join a Clinical Trial? Questions you should ask when thinking about joining a clinical trial include the following: ·
What is the purpose of the clinical trial?
·
What are the standard treatments for Barrett’s esophagus? Why do researchers think the new treatment may be better? What is likely to happen to me with or without the new treatment?
·
What tests and treatments will I need? Will I need surgery? Medication? Hospitalization?
·
How long will the treatment last? How often will I have to come back for follow-up exams?
·
What are the treatment’s possible benefits to my condition? What are the short- and long-term risks? What are the possible side effects?
·
Will the treatment be uncomfortable? Will it make me feel sick? If so, for how long?
·
How will my health be monitored?
·
Where will I need to go for the clinical trial? How will I get there?
·
How much will it cost to be in the study? What costs are covered by the study? How much will my health insurance cover?
·
Will I be able to see my own doctor? Who will be in charge of my care?
·
Will taking part in the study affect my daily life? Do I have time to participate?
·
How do I feel about taking part in a clinical trial? Are there family members or friends who may benefit from my contributions to new medical knowledge?
Keeping Current on Clinical Trials Various government agencies maintain databases on trials. The U.S. National Institutes of Health, through the National Library of Medicine, has
Clinical Trials 33
developed ClinicalTrials.gov to provide patients, family members, and physicians with current information about clinical research across the broadest number of diseases and conditions. The site was launched in February 2000 and currently contains approximately 5,700 clinical studies in over 59,000 locations worldwide, with most studies being conducted in the United States. ClinicalTrials.gov receives about 2 million hits per month and hosts approximately 5,400 visitors daily. To access this database, simply go to their Web site (www.clinicaltrials.gov) and search by “Barrett’s esophagus” (or synonyms). While ClinicalTrials.gov is the most comprehensive listing of NIH-supported clinical trials available, not all trials are in the database. The database is updated regularly, so clinical trials are continually being added. The following is a list of specialty databases affiliated with the National Institutes of Health that offer additional information on trials: ·
For clinical studies at the Warren Grant Magnuson Clinical Center located in Bethesda, Maryland, visit their Web site: http://clinicalstudies.info.nih.gov/
·
For clinical studies conducted at the Bayview Campus in Baltimore, Maryland, visit their Web site: http://www.jhbmc.jhu.edu/studies/index.html
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For trials on diseases of the digestive system and kidneys, and diabetes, visit the National Institute of Diabetes and Digestive and Kidney Diseases: http://www.niddk.nih.gov/patient/patient.htm
General References The following references describe clinical trials and experimental medical research. They have been selected to ensure that they are likely to be available from your local or online bookseller or university medical library. These references are usually written for healthcare professionals, so you may consider consulting with a librarian or bookseller who might recommend a particular reference. The following includes some of the most readily available references (sorted alphabetically by title; hyperlinks provide rankings, information and reviews at Amazon.com): ·
A Guide to Patient Recruitment : Today’s Best Practices & Proven Strategies by Diana L. Anderson; Paperback - 350 pages (2001),
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CenterWatch, Inc.; ISBN: 1930624115; http://www.amazon.com/exec/obidos/ASIN/1930624115/icongroupinterna ·
A Step-By-Step Guide to Clinical Trials by Marilyn Mulay, R.N., M.S., OCN; Spiral-bound - 143 pages Spiral edition (2001), Jones & Bartlett Pub; ISBN: 0763715697; http://www.amazon.com/exec/obidos/ASIN/0763715697/icongroupinterna
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The CenterWatch Directory of Drugs in Clinical Trials by CenterWatch; Paperback - 656 pages (2000), CenterWatch, Inc.; ISBN: 0967302935; http://www.amazon.com/exec/obidos/ASIN/0967302935/icongroupinterna
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The Complete Guide to Informed Consent in Clinical Trials by Terry Hartnett (Editor); Paperback - 164 pages (2000), PharmSource Information Services, Inc.; ISBN: 0970153309; http://www.amazon.com/exec/obidos/ASIN/0970153309/icongroupinterna
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Dictionary for Clinical Trials by Simon Day; Paperback - 228 pages (1999), John Wiley & Sons; ISBN: 0471985961; http://www.amazon.com/exec/obidos/ASIN/0471985961/icongroupinterna
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Extending Medicare Reimbursement in Clinical Trials by Institute of Medicine Staff (Editor), et al; Paperback 1st edition (2000), National Academy Press; ISBN: 0309068886; http://www.amazon.com/exec/obidos/ASIN/0309068886/icongroupinterna
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Handbook of Clinical Trials by Marcus Flather (Editor); Paperback (2001), Remedica Pub Ltd; ISBN: 1901346293; http://www.amazon.com/exec/obidos/ASIN/1901346293/icongroupinterna
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PART II: ADDITIONAL RESOURCES AND ADVANCED MATERIAL
ABOUT PART II In Part II, we introduce you to additional resources and advanced research on Barrett’s esophagus. All too often, patients who conduct their own research are overwhelmed by the difficulty in finding and organizing information. The purpose of the following chapters is to provide you an organized and structured format to help you find additional information resources on Barrett’s esophagus. In Part II, as in Part I, our objective is not to interpret the latest advances on Barrett’s esophagus or render an opinion. Rather, our goal is to give you access to original research and to increase your awareness of sources you may not have already considered. In this way, you will come across the advanced materials often referred to in pamphlets, books, or other general works. Once again, some of this material is technical in nature, so consultation with a professional familiar with Barrett’s esophagus is suggested.
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CHAPTER 4. STUDIES ON BARRETT’S ESOPHAGUS Overview Every year, academic studies are published on Barrett’s esophagus or related conditions. Broadly speaking, there are two types of studies. The first are peer reviewed. Generally, the content of these studies has been reviewed by scientists or physicians. Peer-reviewed studies are typically published in scientific journals and are usually available at medical libraries. The second type of studies is non-peer reviewed. These works include summary articles that do not use or report scientific results. These often appear in the popular press, newsletters, or similar periodicals. In this chapter, we will show you how to locate peer-reviewed references and studies on Barrett’s esophagus. We will begin by discussing research that has been summarized and is free to view by the public via the Internet. We then show you how to generate a bibliography on Barrett’s esophagus and teach you how to keep current on new studies as they are published or undertaken by the scientific community.
The Combined Health Information Database The Combined Health Information Database summarizes studies across numerous federal agencies. To limit your investigation to research studies and Barrett’s esophagus, you will need to use the advanced search options. First, go to http://chid.nih.gov/index.html. From there, select the “Detailed Search” option (or go directly to that page with the following hyperlink: http://chid.nih.gov/detail/detail.html). The trick in extracting studies is found in the drop boxes at the bottom of the search page where “You may refine your search by.” Select the dates and language you prefer, and the
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format option “Journal Article.” At the top of the search form, select the number of records you would like to see (we recommend 100) and check the box to display “whole records.” We recommend that you type in “Barrett’s esophagus” (or synonyms) into the “For these words:” box. Consider using the option “anywhere in record” to make your search as broad as possible. If you want to limit the search to only a particular field, such as the title of the journal, then select this option in the “Search in these fields” drop box. The following is a sample of what you can expect from this type of search: ·
Laparoscopic Cut Collis Gastroplasty: A Novel Technique Source: Diseases of the Esophagus. 11(4): 260-262. October 1998. Contact: Available from Harcourt Brace and Company, Ltd. Journal Subscription Department. Foots Cray, Sidcup, Kent, DA 14 5HP. Summary: This article reports on laparoscopic cut Gollis gastroplasty, which is used for the surgical treatment of gastroesophageal reflux disease (GERD). Patients with severe disease such as Barrett's esophagus, esophageal stricture, or giant mixed hernias may present with the technical difficulty of a shortened esophagus. The authors report on three consecutive patients with shortened esophagus who underwent the Collis gastroplasty laparoscopically. All patients had preoperative esophagitis and failed symptomatic control on proton pump inhibitors. The peristaltic function of all three patients was normal on manometry. The operation duration decreased progressively with familiarization from 240 minutes in the first case to 140 minutes in the third case. Postoperative management consisted of a 48 hour total fast, then a contrast swallow prior to consuming oral fluids. Two patients were discharged well on day 5, and one on day 4, postoperatively. There were no complications, and all three are symptomatically excellent 1, 2, and 3 months postoperatively. All are tolerating a normal diet, and all have control of heartburn and regurgitation; one suffered mild transient dysphagia, which has resolved. Each patient has undergone a delayed barium meal showing intact fundoplication and gastroplasty tube. The authors conclude that laparoscopic Collis gastroplasty appears technically feasible and that further clinical experience to assess the clinical outcome of the operation performed by laparoscopy is justified. 2 figures. 10 references.
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Barrett's Esophagus Source: Scientific American Science and Medicine. 1(5): 16-25. NovemberDecember 1994.
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Contact: Available from Scientific American, Inc. 415 Madison Avenue, New York, NY 10017-1111. Fax (212) 355-0408. E-mail
[email protected]. Summary: Barrett's esophagus, in which the normal stratified squamous epithelium of the lower esophagus is replaced by a specialized columnar metaplastic epithelium, develops in patients as a complication of gastroesophageal reflux disease (GERD). In this article, the author brings readers up-to-date on Barrett's esophagus and its treatment. Topics include the epidemiology of reflux disease and Barrett's-associated adenocarcinomas; the pathogenesis of Barrett's esophagus; anatomic abnormalities that cause GERD; the use of endoscopic biopsy pathology for accurate diagnosis of Barrett's; the management of patients with Barrett's esophagus; the use of DNA content flow cytometry to predict cancer risk in these patients; and methods for the clinical surveillance of patients with Barrett's esophagus. The author stresses that the accessibility of the esophagus, the safety of obtaining mucosal biopsies for analysis, and the ability to repeat biopsies and analyses over time makes Barrett's esophagus a potentially manageable problem, as well as a useful model of multistage carcinogenesis. One sidebar describes the history of this condition and the role of Dr. N.R. Barrett. 11 figures. 11 references. (AA-M).
Federally-Funded Research on Barrett’s Esophagus The U.S. Government supports a variety of research studies relating to Barrett’s esophagus and associated conditions. These studies are tracked by the Office of Extramural Research at the National Institutes of Health.18 CRISP (Computerized Retrieval of Information on Scientific Projects) is a searchable database of federally-funded biomedical research projects conducted at universities, hospitals, and other institutions. Visit the CRISP Web site at http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket. You can perform targeted searches by various criteria including geography, date, as well as topics related to Barrett’s esophagus and related conditions.
18 Healthcare projects are funded by the National Institutes of Health (NIH), Substance Abuse and Mental Health Services (SAMHSA), Health Resources and Services Administration (HRSA), Food and Drug Administration (FDA), Centers for Disease Control and Prevention (CDCP), Agency for Healthcare Research and Quality (AHRQ), and Office of Assistant Secretary of Health (OASH).
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For most of the studies, the agencies reporting into CRISP provide summaries or abstracts. As opposed to clinical trial research using patients, many federally-funded studies use animals or simulated models to explore Barrett’s esophagus and related conditions. In some cases, therefore, it may be difficult to understand how some basic or fundamental research could eventually translate into medical practice. The following sample is typical of the type of information found when searching the CRISP database for Barrett’s esophagus: ·
Project Title: Barrett's Esophagus Surveillance Trial (BEST) Principal Investigator & Institution: Sandler, Robert S.; Professor; Ctr/Gastrointest Biology/Disea; University of North Carolina Chapel Hill Box 2688, 910 Raleigh Rd Chapel Hill, Nc 27515 Timing: Fiscal Year 2000; Project Start 1-MAR-2000; Project End 8-FEB2002 Summary: Barrett's esophagus (BE), defined as the development of intestinal metaplasia in the esophagus, is a premalignant condition that predisposes to adenocarcinoma of the esophagus. The incidence of adenocarcinoma of the gastric cardia and esophagus is increasing more rapidly than any other cancer. The factors responsible for the development of Barrett's esophagus, and the transformation from Barrett's to cancer are largely unknown. In order to prevent the development of cancer, clinicians perform regular endoscopic examinations to discover dysplastic changes that might signal higher risk for cancer. The appropriate surveillance interval is not known. The objective of this application is to seek funds to develop a protocol for a multi-center randomized trial of two different surveillance intervals of patients with Barrett's esophagus. The investigators are members of a clinical trials consortium that has conducted clinical trials for the past decade. The study will test the hypothesis that the currently recommended 2-year surveillance interval can safely be extended to 4 years. The planning grant would provide a mechanism to refine disease definitions, outcome measures, sample size, and analysis plans and to address feasibility issues. A detailed protocol will be developed as part of the planning process. A companion case control study of risk factors for Barrett's will provide new insight into the development and perhaps the prevention of this disease. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket
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Project Title: Chromosome Alterations in Barrett's Esophagus Principal Investigator & Institution: Paulson, Thomas G.; Fred Hutchinson Cancer Research Center Box 19024, 1100 Fairview Ave N Seattle, Wa 98109 Timing: Fiscal Year 2001; Project Start 1-APR-2001; Project End 1-MAR2006 Summary: (Applicant's Description) The incidence of esophageal adenocarcinoma (EA), a rapidly fatal cancer with 5-year survival of less than 10 percent, has risen more then 350 percent over the past 20 years. Neoplastic progression in Barrett's esophagus (BE), the precursor to EA, is characterized by progressive genetic instability, including mutations (p53, p16), promoter hypermethylation (p16), aneuploidy and chromosomal instability (LOH, deletions and amplifications). Barrett's esophagus is an excellent model of human neoplastic progression because endoscopic surveillance is recommended, permitting serial samples to be evaluated over time in the same patient. Shortened telomeres, p53 and p16 inactivation occur before EA. We hypothesize that telomere shortening causes chromosomal instability in BE as has been proposed in model systems. However, relationships among p16/p53 inactivation, reactivation of telomerase, and chromosomal instability during human neoplastic progression are largely unknown. In this proposal, I will investigate the hypothesis that telomere shortening, abrogation of p16 and p53 function and telomerase reactivation interact to mediate chromosomal instability in BE. We propose to measure telomerase activity in BE samples in 325 patients from the Seattle Barrett's Esophagus Cohort, an extremely well characterized cohort for whom p53 and p16 status and flow cytometric data are already known. We will use clonal ordering to determine relationships among p53 inactivation, p16 inactivation, telomerase reactivation and the development of chromosomal instability, using alterations on chromosome 18 as a model of instability. Chromosome 18 is an appropriate model because it is frequently (75 percent of cases) altered in EA (LOH events, amplifications and deletions) and these alterations are selected before the development of cancer. The methods used in these analyses will include TRAP assays to measure telomerase activity and microsatellite LOH and microarray comparative genomic hybridization (CGH) to assess chromosomal instability. The results from these analyses will be of interest to both clinical and basic researchers in studying EA and other cancers. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket
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Project Title: Epidemiologic Case-Control Study of Barrett's Esophagus Principal Investigator & Institution: Shaheen, Nicholas J.; Assistant Professor; Medicine; University of North Carolina Chapel Hill Box 2688, 910 Raleigh Rd Chapel Hill, Nc 27515 Timing: Fiscal Year 2001; Project Start 1-JUL-2001; Project End 0-JUN2006 Summary: The long-term objectives of this project are to advance the understanding of the pathophysiology and management of Barrett's esophagus, and to achieve further formal training in epidemiology and outcomes research for the applicant. Dr. Shaheen, the applicant, is an Assistant Professor at UNC and is Co-Director of the Center for Esophageal Diseases. His mentor, Dr. Robert Sandler, is an established GI epidemiologist, and Director of the Center for Gastrointestinal Biology and Disease (CGIBD). They propose a combined didactic and clinical research experience, utilizing the resources of the UNC School of Public Health, the GI Division and the CGIBD to foster Dr. Shaheen's demonstrated interest in outcomes research. Dr. Dawn Provenzale from Duke University will also provide instruction and mentoring, as well as expertise in the subject area, Barrett's esophagus. The study proposed as part of the clinical training is a case-control study of Barrett's esophagus. Barrett's esophagus is a pre-malignant lesion of esophageal adenocarcinoma, a usually lethal cancer whose incidence is increasing in epidemic proportions. Barrett's is associated with gastroesophageal reflux. Because we cannot adequately stratify risk for Barrett's among those with reflux, authorities recommend that all those with chronic reflux undergo endoscopic screening for Barrett's. Better stratification of Barrett's risk would allow for more targeted usage of screening endoscopy. The specific aims of this study are: 1) To evaluate the relationship between obesity and Barrett's, 2) To assess the role of H. pylori infection and Barrett's, 3) To assess the predictors for dysplasia among those with Barrett's, and, 4) To assess the quality of life of those with Barrett's compared to controls with reflux. The study will recruit 175 cases with reflux symptoms and Barrett's esophagus, and 350 controls with reflux symptoms and no Barrett's who present for endoscopy at UNC. Participants will complete a telephone interview assessing demographics, health habits, risk factors for early H. pylori acquisition, and reflux symptoms. Also, subjects will be administered a measure of quality of life, the Health Status Questionnaire, and a psychological profile, the Revised Hopkins Symptom Checklist. Subjects will undergo assessment of height, weight, hip and waist circumference. Data analysis will compare body mass and fat distribution, as well as risk factors for early H. pylori acquisition, between cases and controls. Subjects with
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Barrett's and dysplasia will be compared to those with Barrett's alone to assess for risk factors for dysplasia. Finally, by comparing subjects with Barrett's to controls with reflux, and controlling for severs of reflux, the impact of a Barrett's diagnosis on quality of life and psychological stress may be seen. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket ·
Project Title: Evolutionary Dynamics of Barrett's Esophagus Neoplasia Principal Investigator & Institution: Maley, Carlo C.; Fred Hutchinson Cancer Research Center Box 19024, 1100 Fairview Ave N Seattle, Wa 98109 Timing: Fiscal Year 2001; Project Start 1-APR-2001; Project End 1-MAR2006 Summary: (Applicant's Description): The cell lineages in neoplastic tissues are evolving under the twin dynamics of mutation and clonal expansion. This is the basis for both its virulence and our difficulties in treating it. We hypothesize that a subset of the mutations observed in the progression to cancer confer beneficial selective effects on the cell. Furthermore, we hypothesize that the interactions between these clonal populations in and around the neoplastic tissue determine the progression to cancer. The aim of this project is to identify these selective mutations and to infer the interactions between the mutant clones in Barrett's Esophagus that eventually lead to the development of esophageal adenocarcinoma. This analysis will be based on loss of heterozygosity data, promoter methylation, single nucleotide polymorphisms, and gene expression data for homogeneous subpopulations of cells sampled from neoplastic tissue in patients with Barrett's Esophagus. The tissue samples come from biopsies of selected patients in the Seattle Barrett's Esophagus Project (N=285). Data mining will be used to identify mutations that are associated with clonal expansion as well as inhibition of neighboring clones. The order of genetic events in the progression to esophageal adenocarcinoma will be determined by phylogenetic reconstruction of the cell lineages in the neoplastic tissue of each patient. Machine learning techniques, such as the EM algorithm, will be employed to infer missing data and the effects of unsampled mutations. Computational modeling will be used to generate comparison data for null hypotheses as well as to generate experimental predictions from our understanding of the progression to cancer. This is the first step in my long-term career goal to contribute to medicine through the use of computational and theoretical methods. Working at the Fred Hutchinson Cancer Research Center will facilitate the transition from my background in computer science and evolutionary
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theory, to an independent research program based on the analysis of cellular and molecular dynamics of cancer. The challenge of this project is the integration of diverse molecular and epidemiological data into a coherent and detailed understanding of the progression to cancer in the neoplasm of a model system. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket ·
Project Title: Familial Aggregation of Barrett's Esophagus Principal Investigator & Institution: Chak, Amitabh; Associate Professor; University Hospitals of Cleveland 11100 Euclid Ave Cleveland, Oh 44106 Timing: Fiscal Year 2002; Project Start 1-MAY-2002; Project End 0-APR2004 Summary: (provided by applicant): Esophageal adenocarcinoma is associated with a very poor prognosis. More effective screening, surveillance, and treatment strategies are required. The overall aim of this pilot proposal is to develop methodologies that will facilitate future multicenter studies aimed at assessing the familial aggregation of Barrett's esophagus and esophageal adenocarcinoma. Three specific methodologies will be developed: 1. A multicenter network will be established at five different institutions to enable the measurement of the prevalence of familial Barrett's esophagus. Familial Barrett's esophagus will be identified by administration of a questionnaire that has already been tested at University Hospitals of Cleveland. 2. Methodology will be developed to screen symptomatic first degree relatives of index patients with Barrett's esophagus and esophageal adenocarcinoma. Relatives with gastroesophageal reflux disease who have already been identified at University Hospitals of Cleveland through the study questionnaire will be recruited for screening endoscopy via mailings and phone calls. 3.Methodology will also be developed to recruit and screen asymptomatic or mildly symptomatic first degree using a new battery powered ultrathin endoscope. Successful conduct of this research proposal will result in the creation of a multi-center network, the identification of families with aggregation of Barrett's esophagus and esophageal adenocarcinoma, and the development of methodology for detecting Barrett's esophagus in previously undiagnosed family members. These three achievements will permit future full-scale multicenter epidemiologic and genetic linkage studies with the ultimate goals of measuring the familial risk of Barrett's esophagus and the identification of susceptibility gene(s) that predispose individuals to the development of Barrett's esophagus. The results of these future investigations will aid the development of lower cost, more effective screening and surveillance programs for Barrett's esophagus. They will
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also define a population at risk in whom interventions to prevent or eradicate Barrett's esophagus can be applied. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket ·
Project Title: Genetic Epidemiology of Barrett's Esophagus Principal Investigator & Institution: Romero, Yvonne; Mayo Clinic Rochester 200 1St St Sw Rochester, Mn 55905 Timing: Fiscal Year 2001; Project Start 1-MAR-2001; Project End 0-NOV2005 Summary: Yvonne Romero's long term career goal is to decrease the mortality rate of esophageal adenocarcinoma. Yvonne is a Harvard undergraduate who completed a 3-year Gastroenterology fellowship at Mayo in 1996, matriculated into the Clinical Epidemiology and Biostatistics Program at McMaster University in 1997, was the first Mayo Fellow in Diseases of the Esophagus in 1998, who joined the staff at Mayo in May 1999. Her clinical mentor, Alan J. Cameron, MD, is a recognized authority on Barrett's esophagus, a premalignant disorder. They have been addressing the question of familial gastroesophageal reflux disease and Barrett's esophagus since 1994. Their first project, which showed aggregation of reflux symptoms in families of probands with Barrett's esophagus and esophageal adenocarcinoma (but not solo reflux esophagitis), was published in Gastroenterology in 1997. In the Barrett's Esophagus Genomic Study, for which Dr. Romero acts as primary investigator, 96 families with 3 or more effected persons have already been identified. A separate pilot study showed a trend of increased Barrett's esophagus prevalence among symptomatic relatives of probands with Barrett's compared to controls. Doctor Romero's immediate goals are to, 1) determine the risk of Barrett's esophagus and reflux esophagitis, the presumed precursor of Barrett's, among relatives of Barrett's probands compared to age-, sex-, medication- and symptommatched controls without significant family history; and 2) collect blood from high- prevalence Barrett's esophagus families. Her intermediate goals are to 1) carry out a genome screen to map the chromosomal location of the gene(s) responsible for the phenotypes of reflux esophagitis and Barrett's esophagus using linkage analysis; 2) detect genetic heterogeneity as there is likely more than one major gene involved; and 3) fine map the genetic region(s) identified through linkage analysis, to identify the smallest genomic segment that contains the gene(s). To pursue this line of evidence in a scientifically stringent manner, Dr. Romero has been enrolled in genetic epidemiology coursework at the University of Minnesota since February 1999 and will continue to do so as supported by this award.
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Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket ·
Project Title: Photodynamic Therapy for Esophageal Malignancies in Barrett's Esophagus Principal Investigator & Institution: Wang, K K.; Mayo Clinic Rochester 200 1St St Sw Rochester, Mn 55905 Timing: Fiscal Year 2000 Summary: With the increasing ability of non-invasive genetic tests to screen groups of patients at high risk of malignancy and the use of endoscopy to detect small malignancies of the gastrointestinal tract, the management of superficial neoplasma becomes more of a clinical dilemma. The small early carcinoma has traditionally been managed with surgical resection although this is associated with significant morbidity and mortality in the gastrointestinal tract especially the esophagus. Barrett's esophagus is a pre-malignant condition of the esophagus that has been diagnosed more frequently currently. The major issues involved in treating superficial neoplasma include accurate staging, type of therapy, and need for careful follow-up. The first major hurdle in implementing endoscopic therapy has been leaped with the development of endoscopic ultrasonography which allows the accurate staging of localized cancers. The second issue involves the ability of an endoscopic treatment to actually cure the primary malignancy which has been suggested based upon several preliminary studies. Photodynamic therapy has been shown to potentially ablate malignant esophageal tissue in 70% of patients treated. We propose to treat patients with superficial carcinomas within Barrett's esophagus who are not candidates for surgery using optimized photodynamic therapy. One of the major limitations to this therapy is predicting uniformity of results. We propose to control this therapy using novel methods. Drug dosimetry will be controlled using novel techniques include a fluorescence probe and a balloon centering device to control light dosimetry. After treatment, patients will be carefully followed to determine if malignant or dysplastic epithelium return. The patients will not only have standard biopsies but also cytology combined with image cytometry to detect the presence of malignancy and dysplasia. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket
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Project Title: A Novel Technique for Screening Barrett's Esosphagus Principal Investigator & Institution: Wang, Kenneth K.; Associate Professor; Mayo Clinic Rochester 200 1St St Sw Rochester, Mn 55905 Timing: Fiscal Year 2000; Project Start 1-APR-2000; Project End 1-MAR2004
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Summary: Gastroesophageal cancers are the most rapidly increasing cancer in Caucasian males and are a consequence of Barrett's esophagus. Barrett's esophagus is a pre-malignant condition that is produced by gastroesophageal reflux disease (heartburn). Screening for Barrett's esophagus can only be accomplished by endoscopy that is expensive and impractical given the population at risk. The purpose of this proposal is to design an "optical biopsy" system that can be applied by a wide range of health care providers to screen for Barrett's esophagus. This system will consist of an optical probe that can be placed into the esophagus with minimal discomfort to the patient that is connected to an optical biopsy console that will provide real time results. The primary design issues will be in constructing a small caliber probe that can be comfortably placed into the esophagus and yet expandable to provide contact with the esophageal wall for an optical biopsy. The second design consideration would be in constructing an algorithm that would analyze the spectroscopic signal from the "optical biopsy" which would distinguish normal and abnormal tissue in the upper gastrointestinal tract. Three proposed probe designs will be evaluated initially in the resected porcine esophagus and stomach to assess deployment of the probes and their safety. Subsequently, the probes will be assessed in the pig model to evaluate their performance characteristics. The best design will be selected for clinical testing. The clinical trials will involve the use of the probe in patients with known Barrett's esophagus and a control group undergoing endoscopy for other indications. The probe would be passed prior to endoscopy and the results compared to the endoscopic findings. The algorithms will be derived from optical and histological biopsies taken simultaneously at endoscopy from patients undergoing surveillance endoscopy for Barrett's esophagus. The development of a screening device for Barrett's esophagus that could be operated by paramedical personnel would enable large-scale low cost screening to identify patients at risk for esophageal cancer. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket ·
Project Title: Barretts Esophagus--Diet Intervention/Intermed Markers Principal Investigator & Institution: Reid, Brian J.; Associate Professor; Fred Hutchinson Cancer Research Center Box 19024, 1100 Fairview Ave N Seattle, Wa 98109 Timing: Fiscal Year 1999; Project Start 1-SEP-1995; Project End 1-AUG2002 Summary: Barrett's esophagus is a condition in which the normal stratified squamous epithelium of the esophagus is replaced by a metaplastic columnar epithelium. It develops as a complication of chronic
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gastroesophageal reflux disease and predisposes to the development of adenocarcinomas of the esophagus and gastric cardia. Barrett's associated adenocarcinomas are the most rapidly increasing cancers in the United States, but they are rarely discovered in time for Cure. Intensive endoscopic biopsy surveillance of patients with Barrett's esophagus can detect early, potentially curable Barrett's adenocarcinomas, but such surveillance is costly and time consuming. Dietary recommendations including a low-fat diet and weight reduction are an accepted part of standard medical therapy for patients with gastroesophageal reflux and Barrett's esophagus, but the efficacy of this diet in reversing intermediate endpoints of neoplastic progression in Barrett's esophagus and decreasing symptoms and mucosal damage associated with reflux has never been established in a randomized, clinical trial. The specific aims of this application for a cooperative agreement are to determine whether a dietary intervention to reduce the intake of dietary fat, increase the intake of fruits and vegetables, and reduce weight can l) reverse intermediate endpoints of neoplastic progression (increased G1 and S phase fractions) in Barrett's esophagus, and 2) lead to partial regression of premalignant metaplasia (as evidenced by the development of islands of normal squamous epithelium in the metaplastic columnar epithelium). Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket ·
Project Title: Barretts Esophagus--Familial Disorder Principal Investigator & Institution: Cameron, Alan; Mayo Clinic Rochester 200 1St St Sw Rochester, Mn 55905 Timing: Fiscal Year 2000 Summary: Aim of study: Barrett's esophagus is a disorder associated with reflux and an increased risk of esophageal cancer. We previously showed an increased prevalence of symptoms of gastroesophageal reflux in first degree relatives of patients with Barrett's esophagus. The aim of the present study is to find whether first degree relatives of patients with Barrett's esophagus have an increased prevalence of this disorder compared to controls with reflux symptoms and no family history of Barrett's esophagus. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket
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Project Title: Biomathematical Approaches to Cancer Principal Investigator & Institution: Moolgavkar, Suresh H.; Professor; Fred Hutchinson Cancer Research Center Box 19024, 1100 Fairview Ave N Seattle, Wa 98109
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Timing: Fiscal Year 2002; Project Start 1-MAR-1988; Project End 0-JUN2006 Summary: (provided by applicant): Clones of intermediate cells on the pathway to cancer, such as adenomatous polyps and altered hepatic foci, are often observed in humans and animals. These lesions provide insights into the earliest stages of the carcinogenic process. Because clonal expansion of cells that are partially transformed can increase the probability of cancer substantially, a quantitative understanding of these lesions is key to understanding cancer rates. The broad objective of this project is to continue the development of mathematical, statistical and computational tools, within the paradigm of multistage carcinogenesis, for the quantitative analyses of early lesions on the pathway to malignancy. The fundamental goals of these analyses are to study the temporal evolution of these lesions, to estimate the rate of initiation of the lesions, and the rates of cell division and apoptosis of the partially transformed cells that comprise the lesion. Information on such early lesions is typically available from initiation-promotion experiments, particularly in the rodent liver.In previous work mathematical expressions have been developed for the number and size distribution of intermediate lesions on the pathway to malignancy and used for analyses of initiation-promotion experiments in rat liver. This proposal plans to extend this work in light of new biological information. In addition to continuing work on analyses of liver foci in rodents, the research proposed here will investigate intermediate lesions in the human colon and in patients with Barrett's esophagus, a high-risk precursor condition for adenocarcinoma of the esophagus. In addition to the mathematical and statistical problems associated with clonal growth models within the paradigm of multistage carcinogenesis, both analyses of liver foci and analyses of lesions in Barrett's esophagus present diverse problems. Recognizing that modeling is an iterative process an integral part of this effort will be collaboration with experimentalists and human biologists, in particular Dr. Michael Schwarz, University of T bingen, an expert on the rodent liver system, Dr. John Potter, an epidemiologist with expertise on colon cancer and Dr. Brian Reid, Director of the Seattle Barrett's Esophagus Project. The results of analyses will be used to help generate biologically relevant questions and hypotheses and to plan further experiments and studies, which, in turn, will lead to more refined models.The comments in the critique section were prepared by the reviewers assigned to this application and are provided without significant modification or editing by staff. The resume and summary of discussion section documents the final outcome of the evaluation by reviewers and is the basis for the assigned priority score
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Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket ·
Project Title: CAT-D Photodynamic Therapy Using Photofrin Principal Investigator & Institution: Berenson, Malcolm M.; ; University of Utah 200 S University St Salt Lake City, Ut 84112 Timing: Fiscal Year 2000; Project Start 1-DEC-1977; Project End 8-FEB2001 Summary: Barrett's esophagus is a condition in which normal tissue in the lower esophagus is replaced by an abnormal, glandular tissue, which has a potential to undergo malignant transformation to cancer of the esophagus. Surveillance for malignant change is recommended, using regular upper gastrointestinal endoscopy. When malignant change becomes imminent, surgical resection is recommended. Recent evidence suggests that surgery might not always be necessary, as local ablative treatments may be sufficient. Photodynamic therapy sensitizes targeted tissues to light-activated chemistry, which has the potential to kill cells. Preliminary data suggest that premalignant changes of Barrett's esophagus may not progress to invasive cancer when treated with photodynamic therapy. This category D study randomizes patients with premalignant Barrett's esophagus to photodynamic therapy with regular surveillance, or to the more conventional treatment with medications designed to suppress acid formation in the stomach (omeprazole), with surveillance every three months. The surveillance includes upper gastrointestinal endoscopy and biopsy. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket
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Project Title: Diagnosis of Dysplasia by Fluorescence Spectroscopy Principal Investigator & Institution: Van Dam, Jacques; Associate Professor; Medicine; Stanford University Stanford, Ca 94305 Timing: Fiscal Year 2000; Project Start 5-SEP-2000; Project End 1-AUG2005 Summary: (Applicant's Description) The goal of this research proposal is to provide salary support to facilitate the advancement and completion of an NCl-funded clinical research proposal. The Principal Investigator, a clinically active physician scientist, is a collaborator on NCI R01 CA 53717 "Real Time In Vivo Diagnosis of Dysplasia by Fluorescence." The goal of the R01 is, in part, to develop endoscope-compatible, fluorescence spectroscopy systems for the real time detection of precancerous (dysplastic) alterations in the luminal gastrointestinal tract. Both fiber optic-based contact probe techniques for localized detection and fluorescence spectral endoscope systems for wide area imaging of disease
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will be developed and applied clinically. Multi-wavelength excitation fluorescence and reflectance system will be used to characterize the optical/spectroscopic properties of relevant tissue types. The results of this study will be used to select optimal excitation wavelength(s) and design fiber probes with controllable sampling depth for targeting detection of superficial lesions. By combining this information with tissue optical parameters, models of colon and esophageal fluorescence measured at colonoscopy and gastroscopy respectively, will be developed. Inverse modeling will be developed for extracting histopathological information from the clinical spectra. The existing fluorescence imaging colonoscope will be modified for additional clinical studies, including application in patients with Barrett's esophagus. The techniques developed in this program will be clinically tested for rapid detection of colorectal dysplasia/carcinoma in chronic ulcerative colitis and dysplasia in Barrett's esophagus and as such are "translational" in nature. Based on extremely successful preliminary data, light (white light) scattering spectroscopy (LSS) will be used to determine the size and degree of "crowding" of nuclei of superficial mucosal cells in the columnar-lined (Barrett's) esophagus. LSS will be used to guide the endoscopic detection (and pathological grading) of mucosal dysplasia. The Principal Investigator is devoted to training clinical researchers and will continue the formalized instruction and mentoring of young clinicians so that they may successfully engage in meaningful clinical research. In this way, the Principal Investigator will help mentor the next generation of physician scientists. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket ·
Project Title: Epidemiology of Barretts Esophagus Principal Investigator & Institution: Vaughan, Thomas L.; Professor and Program Head; Fred Hutchinson Cancer Research Center Box 19024, 1100 Fairview Ave N Seattle, Wa 98109 Timing: Fiscal Year 2000; Project Start 5-SEP-1997; Project End 0-JUN2003 Summary: Barrett's esophagus is a metaplastic condition that develops in an estimated 10-20% of persons with long-standing gastroesophageal reflux disease (GERD). Patients with this condition are at high risk, estimated at 1-2% per year, of developing esophageal adenocarcinoma, a rapidly fatal cancer that, for unknown reasons, has risen sharply in incidence since the mid-1970s. Although much research has been directed toward identifying predictors of progression i patients with Barrett's esophagus, there is little information about the causes of the conditions itself. The first Specific Aim of this case-control study is to compare cases
52 Barrett’s Esophagus
with newly diagnosed Barrett's esophagus (N=335) to controls from the general population (N=335) to test the hypothesis that specific environmental exposures and host factors increase risk of Barrett's metaplasia, and to estimate the fraction of cases attributable to them. Also to be examined will be the role of obesity, diet high in fat and low in fruits and vegetables, low serum vitamin C, vitamin E, carotenoids and selenium, tobacco use, alcohol consumption, use of medications that promote reflux and family history. The second Specific Aim is to identify determinant of Barrett's esophagus among individuals with severe and persistent GERD, by comparing cases to patients undergoing upper endoscopy for reflux symptoms, but who are biopsy-proven negative for Barrett's esophagus (N=335). Specifically, the hypothesis to be tested is that among patients with GERD: 1) cigarette smoking, alcohol consumption and dietary intake of nitrosamines are associated with increased risk of Barrett's esophagus, and that higher dietary intake and serum levels of antioxidants are associated with decreased risk; and 2) duodenogastric reflux (measured as the concentration of bile in fasting gastric juice) is associated with an increased risk of metaplasia. The prevalence of short-segment Barrett's will be estimated among patients undergoing endoscopy for GERD, using the largest sample of endoscoped patients, to date, all biopsied according to a standard protocol. Given that 95% of persons with Barrett's esophagus remain undiagnosed and that esophageal adenocarcinoma survival rates are dismal, the most direct means of reducing esophageal adenocarcinoma incidence amy be by preventing metaplasia, rather than by the surveillance and treatment of patients already diagnosed with the condition. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket ·
Project Title: Raman Spectroscopy Monitoring
for Cancer Diagnosis and
Principal Investigator & Institution: Mourant, Judith R.; Bioscience and Biotechnology; University of Calif-Los Alamos Nat Lab Los Alamos National Laboratory Los Alamos, Nm 87545 Timing: Fiscal Year 2001; Project Start 8-MAY-2001; Project End 8-FEB2006 Summary: (Verbatim from Applicant's Abstract): Our general objective is to enable the application of vibrational spectroscopy to cancer diagnosis and treatment monitoring. The detection of cancer at its earliest stages is crucial, for it greatly improves the likelihood of successful treatment. Traditional methods of diagnosis have relied on physical removal of a portion of tissue and microscopic assessment of morphology. The need
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for tissue removal reduces the area of tissue that can be sampled. A noninvasive technique would eliminate this problem. Furthermore, a noninvasive technique has the potential to allow treatment to begin during the same endoscopic procedure used for diagnosis and reduce other complications associated with tissue removal such as tissue handling and increased risk of infection to the patient. We will focus on developing Raman spectroscopy for detection of precancerous conditions in patients with Barrett's esophagus. Barrett's esophagus is a pathology in which the squamous epithelial lining is replaced by a specialized metaplastic epithelium and the likelihood of adenocarcinoma is increased. Because the microscopic changes of dysplasia are difficult to observe, the entire area of metaplastic epithelium should be sampled. Therefore, Barrett's esophagus is well-suited for a noninvasive diagnostic technique. The methods and techniques developed in this proposal may also find application in other tissues such as the cervix. The second goal of our work is to develop Raman spectroscopy as a method for assessing the effects of treatment. Current methods for monitoring the response of an individual tumor to therapy are unreliable and often difficult to implement during the course of therapy. Development of noninvasive or minimally-invasive optical methods to reliably identify regions of apoptosis and necrosis would provide a simple method for assaying tumor response in each individual cancer patient. Consequently, treatments could be customized. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket
E-Journals: PubMed Central19 PubMed Central (PMC) is a digital archive of life sciences journal literature developed and managed by the National Center for Biotechnology Information (NCBI) at the U.S. National Library of Medicine (NLM).20 Access to this growing archive of e-journals is free and unrestricted.21 To search, go to http://www.pubmedcentral.nih.gov/index.html#search, and type “Barrett’s esophagus” (or synonyms) into the search box. This search gives Adapted from the National Library of Medicine: http://www.pubmedcentral.nih.gov/about/intro.html. 20 With PubMed Central, NCBI is taking the lead in preservation and maintenance of open access to electronic literature, just as NLM has done for decades with printed biomedical literature. PubMed Central aims to become a world-class library of the digital age. 21 The value of PubMed Central, in addition to its role as an archive, lies the availability of data from diverse sources stored in a common format in a single repository. Many journals already have online publishing operations, and there is a growing tendency to publish material online only, to the exclusion of print. 19
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you access to full-text articles. The following is a sample of items found for Barrett’s esophagus in the PubMed Central database: ·
17p (p53) Allelic Losses, 4N(G2/tetraploid) Populations, and Progression to Aneuploidy in Barrett's Esophagus by PC Galipeau, DS Cowan, CA Sanchez, MT Barrett, MJ Emond, DS Levine, PS Rabinovitch, and BJ Reid; 1996 July 9 http://www.pubmedcentral.nih.gov/articlerender.fcgi?rendertype=abst ract&artid=38939
The National Library of Medicine: PubMed One of the quickest and most comprehensive ways to find academic studies in both English and other languages is to use PubMed, maintained by the National Library of Medicine. The advantage of PubMed over previously mentioned sources is that it covers a greater number of domestic and foreign references. It is also free to the public.22 If the publisher has a Web site that offers full text of its journals, PubMed will provide links to that site, as well as to sites offering other related data. User registration, a subscription fee, or some other type of fee may be required to access the full text of articles in some journals. To generate your own bibliography of studies dealing with Barrett’s esophagus, simply go to the PubMed Web site at www.ncbi.nlm.nih.gov/pubmed. Type “Barrett’s esophagus” (or synonyms) into the search box, and click “Go.” The following is the type of output you can expect from PubMed for “Barrett’s esophagus” (hyperlinks lead to article summaries): ·
Cytology of small-cell carcinoma arising in Barrett's esophagus. Author(s): Chen KT. Source: Diagnostic Cytopathology. 2000 September; 23(3): 180-2. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=10945905&dopt=Abstract
PubMed was developed by the National Center for Biotechnology Information (NCBI) at the National Library of Medicine (NLM) at the National Institutes of Health (NIH). The PubMed database was developed in conjunction with publishers of biomedical literature as a search tool for accessing literature citations and linking to full-text journal articles at Web sites of participating publishers. Publishers that participate in PubMed supply NLM with their citations electronically prior to or at the time of publication.
22
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·
Malignant progression in Barrett's esophagus: pathology and molecular biology. Author(s): Mueller J, Werner M, Siewert JR. Source: Recent Results Cancer Res. 2000; 155: 29-41. Review. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=10693236&dopt=Abstract
Vocabulary Builder Adenocarcinoma: organization. [NIH]
A malignant epithelial tumor with a glandular
Algorithms: A procedure consisting of a sequence of algebraic formulas and/or logical steps to calculate or determine a given task. [NIH] Antioxidant: One of many widely used synthetic or natural substances added to a product to prevent or delay its deterioration by action of oxygen in the air. Rubber, paints, vegetable oils, and prepared foods commonly contain antioxidants. [EU] Assay: Determination of the amount of a particular constituent of a mixture, or of the biological or pharmacological potency of a drug. [EU] Asymptomatic: No symptoms; no clear sign of disease present. [NIH] Barium: An element of the alkaline earth group of metals. It has an atomic symbol Ba, atomic number 56, and atomic weight 138. All of its acid-soluble salts are poisonous. [NIH] Bile: An emulsifying agent produced in the liver and secreted into the duodenum. Its composition includes bile acids and salts, cholesterol, and electrolytes. It aids digestion of fats in the duodenum. [NIH] Cardia: That part of the stomach surrounded by the esophagogastric junction, characterized by the lack of acid-forming cells. [NIH] Colonoscopy: Endoscopic examination, therapy or surgery of the luminal surface of the colon. [NIH] Crowding: Behavior with respect to an excessive number of individuals, human or animal, in relation to available space. [NIH] Dysplasia: Abnormality of development; in pathology, alteration in size, shape, and organization of adult cells. [EU] Epidemic: Occurring suddenly in numbers clearly in excess of normal expectancy; said especially of infectious diseases but applied also to any disease, injury, or other health-related event occurring in such outbreaks. [EU] Epithelium: The covering of internal and external surfaces of the body,
56 Barrett’s Esophagus
including the lining of vessels and other small cavities. It consists of cells joined by small amounts of cementing substances. Epithelium is classified into types on the basis of the number of layers deep and the shape of the superficial cells. [EU] Excitation: An act of irritation or stimulation or of responding to a stimulus; the addition of energy, as the excitation of a molecule by absorption of photons. [EU] Fluorescence: The property of emitting radiation while being irradiated. The radiation emitted is usually of longer wavelength than that incident or absorbed, e.g., a substance can be irradiated with invisible radiation and emit visible light. X-ray fluorescence is used in diagnosis. [NIH] Gastrointestinal: Pertaining to or communicating with the stomach and intestine, as a gastrointestinal fistula. [EU] Gastroscopy: Endoscopic examination, therapy or surgery of the interior of the stomach. [NIH] Hepatic: Pertaining to the liver. [EU] Hernia: (he protrusion of a loop or knuckle of an organ or tissue through an abnormal opening. [EU] Homogeneous: Consisting of or composed of similar elements or ingredients; of a uniform quality throughout. [EU] Hybridization: The genetic process of crossbreeding to produce a hybrid. Hybrid nucleic acids can be formed by nucleic acid hybridization of DNA and RNA molecules. Protein hybridization allows for hybrid proteins to be formed from polypeptide chains. [NIH] Invasive: 1. having the quality of invasiveness. 2. involving puncture or incision of the skin or insertion of an instrument or foreign material into the body; said of diagnostic techniques. [EU] Laparoscopy: Examination, therapy or surgery of the abdomen's interior by means of a laparoscope. [NIH] Lesion: Any pathological or traumatic discontinuity of tissue or loss of function of a part. [EU] Metaplasia: The change in the type of adult cells in a tissue to a form which is not formal for that tissue. [EU] Necrosis: The sum of the morphological changes indicative of cell death and caused by the progressive degradative action of enzymes; it may affect groups of cells or part of a structure or an organ. [EU] Neoplastic: Pertaining to or like a neoplasm (= any new and abnormal growth); pertaining to neoplasia (= the formation of a neoplasm). [EU] Nitrosamines: A class of compounds that contain a -NH2 and a -NO radical.
Studies 57
Many members of this group have carcinogenic and mutagenic properties. [NIH]
Oral: Pertaining to the mouth, taken through or applied in the mouth, as an oral medication or an oral thermometer. [EU] Phenotype: The outward appearance of the individual. It is the product of interactions between genes and between the genotype and the environment. This includes the killer phenotype, characteristic of yeasts. [NIH] Precursor: Something that precedes. In biological processes, a substance from which another, usually more active or mature substance is formed. In clinical medicine, a sign or symptom that heralds another. [EU] Prevalence: The number of people in a given group or population who are reported to have a disease. [NIH] Reactivation: The restoration of activity to something that has been inactivated. [EU] Regurgitation: A backward flowing, as the casting up of undigested food, or the backward flowing of blood into the heart, or between the chambers of the heart when a valve is incompetent. [EU] Selenium: An element with the atomic symbol Se, atomic number 34, and atomic weight 78.96. It is an essential micronutrient for mammals and other animals but is toxic in large amounts. Selenium protects intracellular structures against oxidative damage. It is an essential component of glutathione peroxidase. [NIH] Serum: The clear portion of any body fluid; the clear fluid moistening serous membranes. 2. blood serum; the clear liquid that separates from blood on clotting. 3. immune serum; blood serum from an immunized animal used for passive immunization; an antiserum; antitoxin, or antivenin. [EU] Symptomatic: 1. pertaining to or of the nature of a symptom. 2. indicative (of a particular disease or disorder). 3. exhibiting the symptoms of a particular disease but having a different cause. 4. directed at the allying of symptoms, as symptomatic treatment. [EU] Telomerase: Essential ribonucleoprotein reverse transcriptase that adds telomeric DNA to the ends of eukaryotic chromosomes. Telomerase appears to be repressed in normal human somatic tissues but reactivated in cancer, and thus may be necessary for malignant transformation. EC 2.7.7.-. [NIH] Telomere: A terminal section of a chromosome which has a specialized structure and which is involved in chromosomal replication and stability. Its length is believed to be a few hundred base pairs. [NIH] Ultrasonography: The visualization of deep structures of the body by recording the reflections of echoes of pulses of ultrasonic waves directed into the tissues. Use of ultrasound for imaging or diagnostic purposes employs
58 Barrett’s Esophagus
frequencies ranging from 1.6 to 10 megahertz. [NIH] Virulence: The degree of pathogenicity within a group or species of microorganisms or viruses as indicated by case fatality rates and/or the ability of the organism to invade the tissues of the host. [NIH]
Books 59
CHAPTER 5. BOOKS ON BARRETT’S ESOPHAGUS Overview This chapter provides bibliographic book references relating to Barrett’s esophagus. You have many options to locate books on Barrett’s esophagus. The simplest method is to go to your local bookseller and inquire about titles that they have in stock or can special order for you. Some patients, however, feel uncomfortable approaching their local booksellers and prefer online sources (e.g. www.amazon.com and www.bn.com). In addition to online booksellers, excellent sources for book titles on Barrett’s esophagus include the Combined Health Information Database and the National Library of Medicine. Once you have found a title that interests you, visit your local public or medical library to see if it is available for loan.
Book Summaries: Online Booksellers Commercial Internet-based booksellers, such as Amazon.com and Barnes & Noble.com, offer summaries which have been supplied by each title’s publisher. Some summaries also include customer reviews. Your local bookseller may have access to in-house and commercial databases that index all published books (e.g. Books in PrintÒ). The following have been recently listed with online booksellers as relating to Barrett’s esophagus (sorted alphabetically by title; follow the hyperlink to view more details at Amazon.com): ·
Barrett's Esophagus by H.W. Tilanus (Editor), A. E. Attwood (Editor); ISBN: 1402001029;
60 Barrett’s Esophagus
http://www.amazon.com/exec/obidos/ASIN/1402001029/icongroupin terna ·
Barrett's Esophagus [DOWNLOAD: PDF] by Stuart Jon Spechler M.D. (Author); ISBN: B0000647T3; http://www.amazon.com/exec/obidos/ASIN/B0000647T3/icongroupi nterna
·
Barrett's Esophagus and Esophageal Adenocarcinoma by Prateek Sharma (Editor), et al; ISBN: 0632045094; http://www.amazon.com/exec/obidos/ASIN/0632045094/icongroupin terna
·
Barrett's Esophagus: Pathophysiology, Diagnosis and Management by Stuart Jon Spechler (Editor); ISBN: 0444009493; http://www.amazon.com/exec/obidos/ASIN/0444009493/icongroupin terna
The National Library of Medicine Book Index The National Library of Medicine at the National Institutes of Health has a massive database of books published on healthcare and biomedicine. Go to the following Internet site, http://locatorplus.gov/, and then select “Search LOCATORplus.” Once you are in the search area, simply type “Barrett’s esophagus” (or synonyms) into the search box, and select “books only.” From there, results can be sorted by publication date, author, or relevance. The following was recently catalogued by the National Library of Medicine:23 ·
Ambulatory esophageal pH monitoring: practical approach and clinical applications. Author: [edited by] Joel E. Richter; Year: 1997; Baltimore: Williams & Wilkins, c1997; ISBN: 068330355X
·
Atlas of esophageal diseases. Author: editor, Roy C. Orlando; with 22 contributors; Year: 2002; Philadelphia: Current Medicine, c2002; ISBN: 1573401811
In addition to LOCATORPlus, in collaboration with authors and publishers, the National Center for Biotechnology Information (NCBI) is adapting biomedical books for the Web. The books may be accessed in two ways: (1) by searching directly using any search term or phrase (in the same way as the bibliographic database PubMed), or (2) by following the links to PubMed abstracts. Each PubMed abstract has a “Books” button that displays a facsimile of the abstract in which some phrases are hypertext links. These phrases are also found in the books available at NCBI. Click on hyperlinked results in the list of books in which the phrase is found. Currently, the majority of the links are between the books and PubMed. In the future, more links will be created between the books and other types of information, such as gene and protein sequences and macromolecular structures. See http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=Books.
23
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http://www.amazon.com/exec/obidos/ASIN/1573401811/icongroupin terna ·
Barrett's esophagus: pathophysiology, diagnosis, and management. Author: editors, Stuart Jon Spechler and Raj K. Goyal; Year: 1985; New York: Elsevier, c1985; ISBN: 0444009493 http://www.amazon.com/exec/obidos/ASIN/0444009493/icongroupin terna
·
Barrett's esophagus and esophageal adenocarcinoma. Author: edited by Prateek Sharma and Richard E. Sampliner; Year: 2001; Malden, Mass.: Blackwell Science, c2001; ISBN: 0632045094 http://www.amazon.com/exec/obidos/ASIN/0632045094/icongroupin terna
·
Barrett's esophagus. Author: edited by H.W. Tilanus and A.E. Attwood; Year: 2001; Dordrecht; Boston: Kluwer Academic Publishers, 2001; ISBN: 1402001029 (HB: alk. paper) http://www.amazon.com/exec/obidos/ASIN/1402001029/icongroupin terna
·
Cancer of the upper gastrointestinal tract. Author: [edited by] Mitchell C. Posner, Everett E. Vokes, Ralph R. Weichselbaum; Year: 2002; Hamilton: B.C. Decker, 2002; ISBN: 1550091018 http://www.amazon.com/exec/obidos/ASIN/1550091018/icongroupin terna
·
Core temperature measurement during submaximal exercise: esophageal, rectal, and intestinal temperatures. Author: Stuart M.C. Lee, W. Jon Williams, Suzanne M. Schneider; Year: 2000; Houston, Tex.: National Aeronautics and Space Administration, Lyndon B. Johnson Space Center, [2000]
·
Esophageal motility and pH testing: technique and interpretation. Author: editors, Donald O. Casell, Linda L. Diederich, June A. Castell; Year: 2000; Highlands Ranch, Colo.: Sandhill Scientific, c2000; ISBN: 0970710208
·
Esophageal motility testing made easy. Author: edited by Cedric G. Bremner ... [et al.]; Year: 2001; St. Louis, Mo.: Quality Medical Pub., 2001; ISBN: 1576260399 http://www.amazon.com/exec/obidos/ASIN/1576260399/icongroupin terna
·
Esophageal motility testing. Author: edited by Donald O. Castell, June A. Castell; Year: 1994; Norwalk, Conn.: Appleton & Lange, c1994; ISBN: 0838522491 http://www.amazon.com/exec/obidos/ASIN/0838522491/icongroupin terna
62 Barrett’s Esophagus
·
Esophageal mucosa: 300 questions--300 answers. Author: R. Giuli ... [et al.], (eds.); Year: 1994; Amsterdam; New York: Elsevier, 1994; ISBN: 0444817530 (alk. paper) http://www.amazon.com/exec/obidos/ASIN/0444817530/icongroupin terna
·
Esophageal surgery. Author: edited by F. Griffith Pearson ... [et al.]; Year: 2002; New York: Churchill Livingstone, c2002; ISBN: 0443076057 http://www.amazon.com/exec/obidos/ASIN/0443076057/icongroupin terna
·
Esophagus and pharynx. Author: volume editor, Roy C. Orlando; with 16 contributors; Year: 1997; Philadelphia: Current Medicine; distributor, Churchill Livingstone, c1997; ISBN: 0443078556 http://www.amazon.com/exec/obidos/ASIN/0443078556/icongroupin terna
·
Esophagus. Author: edited by Donald O. Castell; Year: 1992; Boston: Little, Brown, c1992; ISBN: 0316157651 http://www.amazon.com/exec/obidos/ASIN/0316157651/icongroupin terna
·
Exposure fluctuations of astronauts due to orientation. Author: J.W. Wilson ... [et al.]; Year: 1993; Washington, DC: NASA Headquarters, 1993
·
Functional investigation of esophageal disease. Author: volume editors, C. Scarpignato, J.-P. Galmiche; Year: 1994; Basel; New York: Karger, 1994; ISBN: 3805556098 (alk. paper) http://www.amazon.com/exec/obidos/ASIN/3805556098/icongroupin terna
·
Longitudinal muscle in esophageal disease. Author: O. Arthur Stiennon; Year: 1995; Madison, Wis.: WRS Press, c1995; ISBN: 096445940X http://www.amazon.com/exec/obidos/ASIN/096445940X/icongroupi nterna
·
Management of upper gastrointestinal cancer. Author: edited by John M. Daly, Thomas P.J. Hennessy, John V. Reynolds; Year: 1999; London; New York: W.B. Saunders, c1999; ISBN: 0702021474 http://www.amazon.com/exec/obidos/ASIN/0702021474/icongroupin terna
·
Manual for the videofluorographic study of swallowing. Author: Jeri A. Logemann; Year: 1993; Austin, Tex.: Pro-Ed, c1993; ISBN: 0890795843 http://www.amazon.com/exec/obidos/ASIN/0890795843/icongroupin terna
·
Oncogene activation in esophageal cancer. Author: Alan G. Casson; Year: 1992; Austin: R.G. Landes Co., c1992; ISBN: 1879702207
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http://www.amazon.com/exec/obidos/ASIN/1879702207/icongroupin terna ·
Pacemakers, cardiac, external, noninvasive electrodes: invasive electrodes, transesophageal. Author: ECRI; Year: 2001; Plymouth Meeting, Pa: ECRI, c2001
·
Photodynamic therapy for head and neck, tracheobronchial, and esophageal cancer. Author: J. C. Smith, N. L. Greer; Year: 1997; Minneapolis, MN: ICSI, 1997
·
Radioisotpe imaging in detection of ectopic gastric mucosa: an evaluation of 99mTc pertechnetate in diagnosis of Meckel's diverticulum and Barrett's esophagus. Author: Berquist, Thomas H. (Thomas Henry), 1945-; Year: 1975; [Minneapolis] 1975
·
Reconstructive surgery of the esophagus. Author: Mark K. Ferguson; Year: 2002; Armonk, NY: Futura Pub. Co., c2002; ISBN: 0879934948 (hardcover: alk. paper) http://www.amazon.com/exec/obidos/ASIN/0879934948/icongroupin terna
·
Surgery of the esophagus, stomach, and small intestine. Author: edited by Christopher Wastell, Lloyd M. Nyhus, Philip E. Donahue; foreword by William Silen; Year: 1995; Boston: Little, Brown, c1995; ISBN: 0316924423 http://www.amazon.com/exec/obidos/ASIN/0316924423/icongroupin terna
·
Surgery of the larynx, trachea, esophagus and neck. Author: William H. Montgomery; Year: 2002; Philadelphia: W.B. Saunders, c2002; ISBN: 0721687083 http://www.amazon.com/exec/obidos/ASIN/0721687083/icongroupin terna
·
Surgery of the oesophagus. Author: edited by T.P.J. Hennessy and A. Cuschieri; Year: 1992; Oxford; Boston: Butterworth Heinemann, 1992; ISBN: 0750614986 http://www.amazon.com/exec/obidos/ASIN/0750614986/icongroupin terna
·
Surgery of the upper gastrointestinal tract. Author: edited by Glyn G. Jamieson, Haile T. Debas; Year: 1994; London; New York: Chapman & Hall Medical, c1994; ISBN: 0412535505 http://www.amazon.com/exec/obidos/ASIN/0412535505/icongroupin terna
·
Surveillance of Barrett's Oesophagus. Author: Margaret Somerville, Ruairidh Milne; Year: 1999; Bristol, UK: South and West Regional Health Authority, 1999
64 Barrett’s Esophagus
·
Update gastroenterology 2000: Barrett's esophagus, colon cancer, and tumor imaging: Postgraduate Course 2000, Brussels, November 25. Author: edited by R. Arnold, J.P. Galmiche; Year: 2000; Montrouge, France: John Libbey Eurotext, c2000; ISBN: 2742003460
Chapters on Barrett’s Esophagus Frequently, Barrett’s esophagus will be discussed within a book, perhaps within a specific chapter. In order to find chapters that are specifically dealing with Barrett’s esophagus, an excellent source of abstracts is the Combined Health Information Database. You will need to limit your search to book chapters and Barrett’s esophagus using the “Detailed Search” option. Go to the following hyperlink: http://chid.nih.gov/detail/detail.html. To find book chapters, use the drop boxes at the bottom of the search page where “You may refine your search by.” Select the dates and language you prefer, and the format option “Book Chapter.” By making these selections and typing in “Barrett’s esophagus” (or synonyms) into the “For these words:” box, you will only receive results on chapters in books. The following is a typical result when searching for book chapters on Barrett’s esophagus: ·
Gastroesophageal Reflux Source: in Wyllie, R. and Hyams, J.S., eds. Pediatric Gastrointestinal Disease. 2nd ed. Philadelphia, PA: W.B. Saunders Company. 1999. p. 164187. Contact: Available from W.B. Saunders Company. Book Order Fulfillment Department, 11830 Westline Industrial Drive, Saint Louis, MO 63146-9988. (800) 545-2522 or (314) 453-7010. Fax (800) 568-5136 or (314) 453-7095. E-mail:
[email protected]. Website: customerservice.wbsaunders.com. Price: $155.00 plus shipping and handling. ISBN: 0721674615. Summary: Gastroesophageal reflux (GER) is one of the most common gastrointestinal problems in children. GER produces a wide variety of symptoms and ranges in severity from physiologic regurgitation of infancy to a life threatening disorder. This chapter on GER in children is from a medical textbook that covers all facets of clinical pediatric gastrointestinal disease. The text emphasizes a clinical focus and incorporates anatomy and physiology considerations into each chapter rather than a separate section. The authors of this chapter touch on the pathophysiology of GER and then review in more detail its clinical manifestations, differential diagnosis, evaluation, and therapy. The authors emphasize that it is important to differentiate between normal
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GER episodes and gastroesophageal reflux disease (GERD) in which GER produces pathologic effects. Topics covered include increased frequency or duration of reflux, increased noxiousness of refluxate, nonesophageal reflux destinations and effects, sleep state, GER disease in infants versus children and adults, epidemiology, regurgitation and its contents, esophagitis and its consequences, asymptomatic esophagitis, complicated esophagitis, peptic stricture, Barrett's esophagus, respiratory symptoms and consequences (including respiratory disorders caused or exacerbated by reflux), neurobehavioral manifestations of reflux, diagnostic considerations, esophageal pH monitoring, general principles of therapy, conservative antireflux measures (including diet therapy), pharmacotherapy (including prokinetic agents, acid reducting agents, mucosal protecting agents), and surgical therapy. 13 figures. 8 tables. 284 references. ·
Acute Upper Gastrointestinal Tract Bleeding Source: in Snape, W.J., ed. Consultations in Gastroenterology. Philadelphia, PA: W.B. Saunders Company. 1996. p. 126-139. Contact: Available from W.B. Saunders Company. Order Fulfillment, 6277 Sea Harbor Drive, Orlando, FL 32887. (800) 545-2522. Fax (800) 8746418 or (407) 352-3445. Price: $125.00. ISBN: 0721646700. Summary: This chapter from a gastroenterology textbook covers acute upper gastrointestinal (GI) tract bleeding. Upper GI (UGI) tract bleeding is a life threatening emergency requiring immediate attention and evaluation, with effective treatment based on accurate diagnosis. Although many patients have minimal or self-limited bleeding, significant hemorrhage is common and mortality is approximately 10 percent. This chapter covers UGI tract bleeding that occurs within the area from the proximal esophagus to the ligament of Treitz. Bleeding site or the lesion responsible for UGI tract bleeding has been shown to be remarkably similar in studies on unselected patients. Peptic ulcer accounts for 40 to 50 percent of bleeding, with varices, gastritis, esophagitis, Mallory-Weiss lesion, vascular extasia, tumors, and others accounting for the majority of the remaining identified sites of bleeding. The authors outline the clinical presentation, stabilizing the patient, and developing an appropriate diagnostic and therapeutic plan. Endoscopy is recommended as it provides not only excellent visualization of the UGI tract, but can also permit assessment of multiple potential sites of bleeding, as well as offer therapeutic modalities to control bleeding. The latter half of the chapter outlines therapy for specific bleeding lesions, including bleeding peptic ulcer, variceal hemorrhage, erosive gastritis, portal hypertensive gastropathy, Mallory-Weiss tear, peptic esophagitis,
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neoplasm, vascular ectasia, Dieulafoy's lesion, aortoenteric fistula, and miscellaneous lesions. The authors conclude that the ultimate successful approach to managing UGI tract bleeding relies on the efforts of a skilled multidisciplinary team working together to effect the best outcome for the patient. 6 figures. 3 tables. 11 references. (AA-M). ·
Gastrointestinal Disorders Source: in Lysen, L.K. Quick Reference to Clinical Dietetics. Gaithersburg, MD: Aspen Publishers, Inc. 1997. p. 43-57. Contact: Available from Aspen Publishers, Inc. Fulfillment, 7201 McKinney Circle, Frederick, MD 21704. (800) 234-1660 or (800) 638-8437. Price: $35.00. ISBN: 0834206293. Summary: This section on gastrointestinal disorders is from a reference book on clinical dietetics and is part of a chapter on the use of nutrition management for specific medical conditions. Gastrointestinal (GI) disorders often result in maldigestion and malabsorption of nutrients and present as diarrhea. Diarrhea can have severe nutritional consequences through loss of essential nutrients such as water, minerals, vitamins, electrolytes, and micronutrients. Severe diarrhea can disrupt nutrient absorption to such an extent that malnutrition can occur. GI disorders can be both the cause and result of life threatening conditions. Disruption of the normal processes of nutrient digestion and absorption causes malnutrition, which may lead to serious clinical complications. After a brief review of the anatomy of the GI tract, the author discusses digestion, absorption, secretion, motility, adaptation, the immunologic barrier of the GI tract (the mucosa), nutritional implications in the assessment of the GI tract, factors that may affect the ability to deliver appropriate nutritional support, and specific disorders. These include swallowing difficulties (dysphagia); reflux esophagitis or gastroesophageal reflux disease (GERD); achalasia (motility disorder of the esophagus); esophageal perforation, obstruction, and varices; peptic ulcer disease; gastritis; vomiting; hiatal hernia; gastric outlet obstruction; GI bleeding; dumping syndrome; bezoar formation; absorption disorders; obstruction of the small intestine; lactase deficiency; inflammatory bowel disease; and short bowel syndrome. 7 tables. 10 references.
·
Gastrointestinal Diseases Source: in Gerber, J.M. Handbook of Preventive and Therapeutic Nutrition. Frederick, MD: Aspen Publishers, Inc. 1993. p. 46-49.
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Contact: Available from Aspen Publishers, Inc. 7201 McKinney Circle, Frederick, MD 21701-9782. (800) 638-8437 or (301) 417-7500. Price: $34. ISBN: 0834203189. Summary: This chapter, from a handbook of preventive and therapeutic nutrition, provides an overview about gastrointestinal diseases. Diseases covered include reflux esophagitis and hiatal hernia; peptic ulcer; irritable bowel syndrome; Crohn's disease (regional enteritis); and ulcerative colitis. In each section, brief information is presented about the clinical features and therapy/management of the condition. One exhibit lists substances that may cause upper gastrointestinal symptoms in some patients. 1 table. ·
Gastrointestinal Disease Source: in Scully, C.; Cawson, R.A. Medical Problems in Dentistry. 3rd ed. Woburn, MA: Butterworth-Heinemann. 1993. p. 189-214. Contact: Available from Butterworth-Heinemann. 255 Wildwood Avenue, Woburn, MA 01801. (800) 366-2665. Fax (800) 446-6520. Price: $85.00. Summary: In this chapter, from an extensive text on medical problems in dentistry, the authors discuss gastrointestinal disease, limiting their discussion to those oral complaints for which there may be important medical implications. Topics include oral ulcers, including recurrent aphthae; dry mouth (xerostomia), including that caused by Sjogren's syndrome; HIV infection; sialorrhea (hypersalivation); salivary gland swellings; Frey's syndrome; cervical lymph node enlargement; oral pigmentation; discoloration of teeth; teething; burning mouth; halitosis and disturbed taste sensation; congenital disorders; esophageal disease; dysphagia; reflux esophagitis; the normal function of the stomach; peptic ulcer; cancer of the stomach; small intestine disease; dermatitis herpetiformis; Crohn's disease; acute pancreatitis; chronic pancreatitis; pancreatic tumors; ulcerative colitis; diverticular disease; irritable bowel syndrome; familial polyposis coli; carcinoma of the colon; and antibioticassociated (pseudomembranous) colitis. For each condition discussed, the authors provide brief information about the clinical aspects, the general management, and the dental aspects. 1 figure. 12 tables. 50 references.
·
Esophagitis and Barrett's Esophagus in Children Source: in Brandt, L., et al., eds. Clinical Practice of Gastroenterology. Volume Two. Philadelphia, PA: Current Medicine. 1999. p. 1258-1262. Contact: Available from W.B. Saunders Company. Order Fulfillment, 6277 Sea Harbor Drive, Orlando, FL 32887. (800) 545-2522. Fax (800) 874-
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6418 or (407) 352-3445. Website: www.wbsaunders.com. Price: $235.00 plus shipping and handling. ISBN: 0443065209 (two volume set); 0443065217 (volume 1); 0443065225 (volume 2). Summary: Gastroesophageal (GE) reflux is responsible for most cases of esophagitis in children. This chapter on esophagitis and Barrett's esophagus in children is from a lengthy textbook that brings practitioners up to date on the complexities of gastroenterology practice, focusing on the essentials of patient care. This chapter focuses on the special features of reflux esophagitis as it pertains to children. The specific mechanisms that lead to reflux esophagitis in children are similar to those in adults, i.e., transient lower esophageal sphincter relaxations, hypotonic lower esophageal sphincter, poor esophageal clearance, hiatal hernia, and delayed gastric emptying. Certain underlying disorders predispose children to pathologic GE reflux: neurologic impairment, repaired esophageal atresia, chronic lung disease (especially cystic fibrosis), and hiatal hernia. As in adults, upper GI endoscopy usually is the definitive study to determine the presence of esophagitis or Barrett's esophagus. In nonerosive reflux esophagitis, symptoms usually respond to measures such as lifestyle changes and prokinetic drugs or H2 receptor antagonists. Erosive esophagitis usually is chronic and relapsing, with the risk of stricture formation, and usually requires antireflux surgery or long term proton pump inhibitor use. Barrett's esophagus (BE), the presence of precancerous cells in the esophagus, is much less prevalent in children than in adults, and in childhood BE there is a high prevalence of serious, underlying coexisting disorders. Comorbidities can include neurologic impairment, chronic lung disease, esophageal atresia, and problems arising from chemotherapy for malignancies. 1 table. 27 references.
General Home References In addition to references for Barrett’s esophagus, you may want a general home medical guide that spans all aspects of home healthcare. The following list is a recent sample of such guides (sorted alphabetically by title; hyperlinks provide rankings, information, and reviews at Amazon.com): · The Digestive System (21st Century Health and Wellness) by Regina Avraham; Library Binding (February 2000), Chelsea House Publishing (Library); ISBN: 0791055264; http://www.amazon.com/exec/obidos/ASIN/0791055264/icongroupinterna · American College of Physicians Complete Home Medical Guide (with Interactive Human Anatomy CD-ROM) by David R. Goldmann (Editor), American College of Physicians; Hardcover - 1104 pages, Book & CD-Rom
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edition (1999), DK Publishing; ISBN: 0789444127; http://www.amazon.com/exec/obidos/ASIN/0789444127/icongroupinterna · The American Medical Association Guide to Home Caregiving by the American Medical Association (Editor); Paperback - 256 pages 1 edition (2001), John Wiley & Sons; ISBN: 0471414093; http://www.amazon.com/exec/obidos/ASIN/0471414093/icongroupinterna · Anatomica : The Complete Home Medical Reference by Peter Forrestal (Editor); Hardcover (2000), Book Sales; ISBN: 1740480309; http://www.amazon.com/exec/obidos/ASIN/1740480309/icongroupinterna · The HarperCollins Illustrated Medical Dictionary : The Complete Home Medical Dictionary by Ida G. Dox, et al; Paperback - 656 pages 4th edition (2001), Harper Resource; ISBN: 0062736469; http://www.amazon.com/exec/obidos/ASIN/0062736469/icongroupinterna · Mayo Clinic Guide to Self-Care: Answers for Everyday Health Problems by Philip Hagen, M.D. (Editor), et al; Paperback - 279 pages, 2nd edition (December 15, 1999), Kensington Publishing Corp.; ISBN: 0962786578; http://www.amazon.com/exec/obidos/ASIN/0962786578/icongroupinterna · The Merck Manual of Medical Information : Home Edition (Merck Manual of Medical Information Home Edition (Trade Paper) by Robert Berkow (Editor), Mark H. Beers, M.D. (Editor); Paperback - 1536 pages (2000), Pocket Books; ISBN: 0671027263; http://www.amazon.com/exec/obidos/ASIN/0671027263/icongroupinterna
Vocabulary Builder Antibiotic: A chemical substance produced by a microorganism which has the capacity, in dilute solutions, to inhibit the growth of or to kill other microorganisms. Antibiotics that are sufficiently nontoxic to the host are used as chemotherapeutic agents in the treatment of infectious diseases of man, animals and plants. [EU] Cervical: Pertaining to the neck, or to the neck of any organ or structure. [EU] Chemotherapy: The treatment of disease by means of chemicals that have a specific toxic effect upon the disease - producing microorganisms or that selectively destroy cancerous tissue. [EU] Diarrhea: Passage of excessively liquid or excessively frequent stools. [NIH] Diverticulum: A pathological condition manifested as a pouch or sac opening from a tubular or sacular organ. [NIH] Ectopic: Pertaining to or characterized by ectopia. [EU]
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Electrolyte: A substance that dissociates into ions when fused or in solution, and thus becomes capable of conducting electricity; an ionic solute. [EU] Enteritis: Inflammation of the intestine, applied chiefly to inflammation of the small intestine; see also enterocolitis. [EU] Fibrosis: The formation of fibrous tissue; fibroid or fibrous degeneration [EU] Fistula: An abnormal passage or communication, usually between two internal organs, or leading from an internal organ to the surface of the body; frequently designated according to the organs or parts with which it communicates, as anovaginal, brochocutaneous, hepatopleural, pulmonoperitoneal, rectovaginal, urethrovaginal, and the like. Such passages are frequently created experimentally for the purpose of obtaining body secretions for physiologic study. [EU] Halitosis: An offensive, foul breath odor resulting from a variety of causes such as poor oral hygiene, dental or oral infections, or the ingestion of certain foods. [NIH] Hemorrhage: Bleeding or escape of blood from a vessel. [NIH] Larynx: An irregularly shaped, musculocartilaginous tubular structure, lined with mucous membrane, located at the top of the trachea and below the root of the tongue and the hyoid bone. It is the essential sphincter guarding the entrance into the trachea and functioning secondarily as the organ of voice. [NIH] Ligament: A band of fibrous tissue that connects bones or cartilages, serving to support and strengthen joints. [EU] Malabsorption: Impaired intestinal absorption of nutrients. [EU] Micronutrients: Essential dietary elements or organic compounds that are required in only small quantities for normal physiologic processes to occur. [NIH]
Neurologic: Pertaining to neurology or to the nervous system. [EU] Pancreatitis: Inflammation (pain, tenderness) of the pancreas; it can make the pancreas stop working. It is caused by drinking too much alcohol, by disease in the gallbladder, or by a virus. [NIH] Peptic: Pertaining to pepsin or to digestion; related to the action of gastric juices. [EU] Perforation: 1. the act of boring or piercing through a part. 2. a hole made through a part or substance. [EU] Physiologic: Normal; not pathologic; characteristic of or conforming to the normal functioning or state of the body or a tissue or organ; physiological. [EU]
Pigmentation: 1. the deposition of colouring matter; the coloration or discoloration of a part by pigment. 2. coloration, especially abnormally
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increased coloration, by melanin. [EU] Proximal: Nearest; closer to any point of reference; opposed to distal. [EU] Secretion: 1. the process of elaborating a specific product as a result of the activity of a gland; this activity may range from separating a specific substance of the blood to the elaboration of a new chemical substance. 2. any substance produced by secretion. [EU] Sphincter: A ringlike band of muscle fibres that constricts a passage or closes a natural orifice; called also musculus sphincter. [EU] Trachea: The cartilaginous and membranous tube descending from the larynx and branching into the right and left main bronchi. [NIH] Vascular: Pertaining to blood vessels or indicative of a copious blood supply. [EU] Xerostomia: Dryness of the mouth from salivary gland dysfunction, as in Sjögren's syndrome. [EU]
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CHAPTER 6. MULTIMEDIA ON BARRETT’S ESOPHAGUS Overview Information on Barrett’s esophagus can come in a variety of formats. Among multimedia sources, video productions, slides, audiotapes, and computer databases are often available. In this chapter, we show you how to keep current on multimedia sources of information on Barrett’s esophagus. We start with sources that have been summarized by federal agencies, and then show you how to find bibliographic information catalogued by the National Library of Medicine. If you see an interesting item, visit your local medical library to check on the availability of the title.
Bibliography: Multimedia on Barrett’s Esophagus The National Library of Medicine is a rich source of information on healthcare-related multimedia productions including slides, computer software, and databases. To access the multimedia database, go to the following Web site: http://locatorplus.gov/. Select “Search LOCATORplus.” Once in the search area, simply type in Barrett’s esophagus (or synonyms). Then, in the option box provided below the search box, select “Audiovisuals and Computer Files.” From there, you can choose to sort results by publication date, author, or relevance. The following multimedia has been indexed on Barrett’s esophagus. For more information, follow the hyperlink indicated: ·
Barrett's esophagus : a multistage model of human carcinogensis. Source: Douglas S. Levine; Year: 1994; Format: Videorecording; Secaucus, N.J.: Network for Continuing Medical Education, 1994
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·
Barrett's esophagus : basic science: recorded at DDW 1994 in New Orleans. Source: AGA; Year: 1994; Format: Sound recording; [Bethesda, Md.]: The Association, [1994?]
·
Barrett's esophagus : recorded at DDW 1994 in New Orleans. Year: 1994; Format: Sound recording; [Bethesda, Md.]: American Gastroenterology [i.e. Gastroenterological] Association, [1994]
·
Barrett's esophagus : recorded at DDW 1995 in San Diego. Source: AGA; Year: 1995; Format: Sound recording; [Bethesda, Md.]: American Gastroenterological Association, [1995?]
·
Can the GI prevent cancer? : colon cancer & Barrett's esophagus: recorded at DDW 1995 in San Diego. Source: AGA, American Gastroenterological Association; Year: 1995; Format: Sound recording; [Bethesda, Md.]: The Association, [1995?]
·
Cancer of the upper gastrointestinal tract. Source: Mitchell C. Posner, Everett E. Vokes, Ralph R. Weichselbaum; Year: 2002; Format: Edited by; Hamilton: B.C. Decker, 2002
·
Diagnosis and treatment of Barrett's syndrome. Source: Paul H. Jordan, Enrique H. Longhi; produced by Medical Communications, Dept. of Surgery, Baylor College of Medicine; Year: 1969; Format: Motion picture; Houston, Tex.: The College; [Danbury, Conn.: for loan by Davis and Geck, Film Library; Houston, Tex.: for loan and sale by Baylor College of Medicine, Learning Resource Center, 1969]
·
Dissection of periesophageal space : floppy Nissen fundoplication. Source: produced by Cine´-Med productions; Year: 1989; Format: Videorecording; Woodbury, Conn.: Cine´-Med, c1989
·
Distal esophageal resection and reconstruction by isolated jejunal loop interposition in postsurgical recurrence of obstruction. Source: from the Film Library and the Clinical Congress of ACS; "Doce de Octubre" University Hospital Medical Schoo; Year: 1995; Format: Videorecording; Woodbury, CT: Ciné-Med, [1995]
·
Endoscopic detection and management of Barrett's esophagus. Source: author, Tom R. DeMeester; produced by DG, Davis & Geck, Medical Device Division; Year: 1987; Format: Videorecording; [Wayne, N.J.]: American Cyanamid, c1987
·
Esophageal contraction and peristalsis : mechanisms: recorded at DDW 1994 in New Orleans. Source: AGA; Year: 1994; Format: Sound recording; [Bethesda, Md.]: The Association, [1994?]
·
Esophageal disorders. Source: [authors, Stuart Jon Spechler ... et al.]; Year: 1995; Format: Slide; Timonium, MD: American Gastroenterological Assoc., c1995
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·
Esophagectomy and gastric pull-up. Source: American College of Surgeons; Year: 1991; Format: Videorecording; Lund, Sweden: University Hospital, Dept. of Surgery, c1991
·
Esophagectomy in a patient with polysplenia : technical considerations. Source: American College of Surgeons; from the Film Library and the Clinical Congress of ACS; produced by the SCVMC Media Dept; Year: 1995; Format: Videorecording; [Woodbury, Conn.]: Ciné-Med, distributor, 1995
·
Esophago-gastrectomy using the Ivor Lewis technique for treatment of Barrett's esophagus with stricture and severe mucosal dysplasia. Source: an educational service provided by Glaxo, Inc.; produced by Ciné-Med, Inc; Year: 1992; Format: Videorecording; [Research Triangle Park, N.C.]: Glaxo, c1992
·
Insights into the technique of laparoscopic Nissen fundoplication ; Aberrant left hepatic artery in laparoscopic esophageal or gastric surgery; Laparoscopic esophageal lengthening procedure. Source: Society American Gastrointestinal Endoscopic; Year: 1995; Format: Videorecording; Woodbury, Conn.: Ciné-Med, [1995]
·
Laparoscopic Heller myotomy and diverticulotomy for distal diffuse esophageal spasm ; Esophagogastroscopy during endosurgical Heller myotomy; Endoscopic diverticulo-esophagostomy for Zenker's diverticulum. Source: Society American Gastrointesti; Year: 1997; Format: Videorecording; Woodbury, Conn.: Ciné-Med, [1997?]
·
Laparoscopic highly selective vagotomy. Source: American College of Surgeons; USC University Hospital; Year: 1999; Format: Videorecording; [Woodbury, Conn.]: Distributed by Ciné-Med, [1999]
·
Laparoscopic Hill repair : a definitive anti-reflux procedure. Source: from the Film Library and the Clinical Congress of ACS; a Swedish Medical Center Department Medical Photography & Illustration Production; Year: 1996; Format: Videorecording; Woodbury, CT: CinéMed, [1996]
·
Laparoscopic Nissen fundoplication in children. Source: by Thom E. Lobe; from the Film Library and the Clinical Congress of ACS; Year: 1992; Format: Videorecording; Memphis, Tenn.: Thom E. Lobe, c1992
·
Laparoscopic repair of paraesophageal hernias. Source: an educational service provided by DG, Davis+Geck; produced by Cine´-Med; Year: 1993; Format: Videorecording; Woodbury, Conn.: American Cyanamid Co., c1993
·
Laparoscopic techniques of esophagogastrectomy. Source: [presented by] American College of Surgeons [and] Ciné-Med; produced by Cedars-
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Sinai Medical Center, Medical Media Services; Year: 1996; Format: Videorecording; Woodbury, CT: Ciné-Med., c1996 ·
Management of esophageal disorders. Source: [presented by] the American Academy of Family Physicians; developed and produced by Gardiner-Caldwell SynerMed; Year: 1988; Format: Videorecording; [Kansas City, Mo.]: The Academy, c1988
·
Mini cervicoscopic esophageal myotomy for swallowing disorder. Source: from the Film Library and the Clinical Congress of ACS, LAC & USC Medical Center, University of Southern California, Los Angeles; Year: 2000; Format: Videorecording; [Woodbury, Conn.]: Ciné-Med, [2000]
·
New directions in treatment of premalignant and malignant lesions of the esophagus. Source: Society of Surgical Oncology Cancer Symposium, March 16-19, 2000, New Orleans, Louisiana; Year: 2000; Format: Videorecording; Chicago, IL: Teach 'em [distributor], 2000
·
Operation for a fistula between the brachiocephalic artery and the esophageal substitute after esophagectomy. Source: from the Film Library and the Clinical Congress of ACS; Year: 1996; Format: Videorecording; Woodbury, CT: Ciné-Med, [1996]
·
Partial esophagectomy followed by free jejunal graft for esophageal cancer at the cervicothoracic junction [videorecording. Source: from the Film Library and the Clinical Congress of ACS; Year: 1996; Woodbury, CT: Ciné-Med, [1996]
·
Partial gastric transposition for esophageal atresia as primary procedure. Source: from the Film Library and the Clinical Congress of ACS; Year: 1996; Format: Videorecording; Woodbury, CT: Ciné-Med, c1996
·
Technique of laparoscopic Toupet fundoplication ; Laparoscopic collis gastroplasty, the preferred treatment for the shortened esophagus. Source: Society American Gastrointestinal Endoscopic Surgeons, SAGES; Year: 1996; Format: Videorecording; Woodbury, Conn.: Ciné-Med, [1996?]
·
Therapeutic endoscopy : approach to foreign bodies, gastrointestinal strictures, and endoscopic feeding. Source: Jeffrey L. Ponsky; Year: 1998; Format: Videorecording; Timonium, MD: Milner-Fenwick, [1998]
Vocabulary Builder Artery: A large blood vessel that carries blood from the heart to other parts of the body. Arteries are thicker and have walls that are stronger and more
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elastic than the walls of veins. [NIH] Peristalsis: The wormlike movement by which the alimentary canal or other tubular organs provided with both longitudinal and circular muscle fibres propel their contents. It consists of a wave of contraction passing along the tube for variable distances. [EU]
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CHAPTER 7. PERIODICALS AND NEWS ON BARRETT’S ESOPHAGUS Overview Keeping up on the news relating to Barrett’s esophagus can be challenging. Subscribing to targeted periodicals can be an effective way to stay abreast of recent developments on Barrett’s esophagus. Periodicals include newsletters, magazines, and academic journals. In this chapter, we suggest a number of news sources and present various periodicals that cover Barrett’s esophagus beyond and including those which are published by patient associations mentioned earlier. We will first focus on news services, and then on periodicals. News services, press releases, and newsletters generally use more accessible language, so if you do chose to subscribe to one of the more technical periodicals, make sure that it uses language you can easily follow.
News Services & Press Releases Well before articles show up in newsletters or the popular press, they may appear in the form of a press release or a public relations announcement. One of the simplest ways of tracking press releases on Barrett’s esophagus is to search the news wires. News wires are used by professional journalists, and have existed since the invention of the telegraph. Today, there are several major “wires” that are used by companies, universities, and other organizations to announce new medical breakthroughs. In the following sample of sources, we will briefly describe how to access each service. These services only post recent news intended for public viewing.
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PR Newswire Perhaps the broadest of the wires is PR Newswire Association, Inc. To access this archive, simply go to http://www.prnewswire.com. Below the search box, select the option “The last 30 days.” In the search box, type “Barrett’s esophagus” or synonyms. The search results are shown by order of relevance. When reading these press releases, do not forget that the sponsor of the release may be a company or organization that is trying to sell a particular product or therapy. Their views, therefore, may be biased. The following is typical of press releases that can be found on PR Newswire: ·
Breakthrough Therapy for Barrett's Esophagus Summary: San Francisco, June 28 /PRNewswire/ -- BARRx Medical announced a breakthrough therapy for Barrett's esophagus at MedTech Insight's "Investment in Innovation Conference" today in San Francisco. Barrett's esophagus is a pre-cancerous condition caused by chronic, severe acid reflux for which no effective therapy exists. Left untreated, Barrett's can progress to esophageal cancer, one of the deadliest forms of cancer. The disease is difficult to diagnose and requires repeated endoscopic procedures coupled with random biopsies of suspect tissue. Because of the medical community's need to more effectively manage Barrett's, numerous experimental therapies are under investigation. Roger Stern, Ph.D., a BARRx founder and President of Stellartech Research Corporation said, "BARRx Medical has developed a therapy with the safety, efficacy, and cost-effectiveness to be routinely adopted by gastroenterologists for the treatment of Barrett's. We believe that none of the other therapies currently being investigated offers a workable solution." The BARRx System consists of a custom Radio Frequency (RF) Generator and single-use treatment catheter. The catheter is inserted endoscopically, and positioned at the desired site. A short, controlled application of RF energy destroys the thin layer of pre-cancerous cells. Normal function of the esophagus' muscular layer is preserved. The entire procedure is performed rapidly, adding an estimated 15 minutes to an endoscopy. The company believes its device will change the risk/benefit ratio in favor of early treatment of Barrett's, the way colonoscopy changed the treatment of colon polyps. Prior to 1975, pre-cancerous colon polyps, like pre-cancerous Barrett's, could only be removed via invasive surgery. Since the risk of surgery outweighed the risk of developing cancer,
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polyps were left in place, followed with serial barium contrast x-rays and removed only if they appeared to be growing. Dr. Robert Ganz, Chief of Gastroenterology at Abbott-Northwestern Hospital and a BARRx founder, said, "Right now the risk/benefit ratio is skewed toward following, rather than treating, Barrett's patients. If a safe, easy, consistent therapy becomes available that takes care of the problem in a single treatment like colonoscopy does for colon polyps, the risk/benefit ratio would shift to treatment of Barrett's overnight." To date, BARRx Medical has been incubated at Stellartech Research Corporation, a full-service contract design, development and manufacturing company located in Sunnyvale, California. The BARRx device has received FDA 510(k) clearance for treatment of Barrett's esophagus. The company is seeking funding to build company infrastructure and prepare for commercialization.
Reuters The Reuters’ Medical News database can be very useful in exploring news archives relating to Barrett’s esophagus. While some of the listed articles are free to view, others can be purchased for a nominal fee. To access this archive, go to http://www.reutershealth.com/frame2/arch.html and search by “Barrett’s esophagus” (or synonyms). The following was recently listed in this archive for Barrett’s esophagus: ·
Axcan files Photofrin with FDA for Barrett's Esophagus dysplasia Source: Reuters Industry Breifing Date: May 30, 2002 http://www.reuters.gov/archive/2002/05/30/business/links/20020530 rglt005.html
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Axcan files Barrett's esophagus dysplasia drug for EU approval Source: Reuters Industry Breifing Date: April 11, 2002 http://www.reuters.gov/archive/2002/04/11/business/links/20020411 rglt007.html
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Screening boosts survival in Barrett's esophagus Source: Reuters Health eLine Date: April 01, 2002 http://www.reuters.gov/archive/2002/04/01/eline/links/20020401elin 040.html
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·
Cancer surveillance may improve survival for patients with Barrett's esophagus Source: Reuters Medical News Date: March 29, 2002 http://www.reuters.gov/archive/2002/03/29/professional/links/20020 329epid004.html
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COX-2 inhibitors may be useful treatment for Barrett's esophagus Source: Reuters Industry Breifing Date: March 20, 2002 http://www.reuters.gov/archive/2002/03/20/business/links/20020320 scie002.html
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Peers influences adoption of new treatment for Barrett's esophagus Source: Reuters Industry Breifing Date: March 11, 2002 http://www.reuters.gov/archive/2002/03/11/business/links/20020311 prof002.html
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GERD symptoms and hiatal hernia are risk factors for Barrett's esophagus Source: Reuters Medical News Date: January 29, 2002 http://www.reuters.gov/archive/2002/01/29/professional/links/20020 129epid003.html
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Controversy surrounds treatment of high-grade dysplasia in Barrett's esophagus Source: Reuters Medical News Date: July 23, 2001 http://www.reuters.gov/archive/2001/07/23/professional/links/20010 723clin008.html
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Dusa announces new study of Levulan PDT for Barrett's esophagus Source: Reuters Industry Breifing Date: April 06, 2001 http://www.reuters.gov/archive/2001/04/06/business/links/20010406 drgd002.html
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Colonization with cagA-positive H. pylori may prevent Barrett's esophagus Source: Reuters Medical News Date: October 09, 2000 http://www.reuters.gov/archive/2000/10/09/professional/links/20001 009epid004.html
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·
Several factors predict risk of progression of Barrett's esophagus to cancer Source: Reuters Medical News Date: July 28, 2000 http://www.reuters.gov/archive/2000/07/28/professional/links/20000 728clin003.html
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Progression of Barrett's esophagus related to presence of hiatal hernia Source: Reuters Medical News Date: December 24, 1999 http://www.reuters.gov/archive/1999/12/24/professional/links/19991 224clin007.html
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Regression of Barrett's esophagus seen with elimination of acid reflux Source: Reuters Medical News Date: September 29, 1999 http://www.reuters.gov/archive/1999/09/29/professional/links/19990 929clin014.html
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Adenocarcinoma less common than expected in Barrett's esophagus Source: Reuters Medical News Date: August 23, 1999 http://www.reuters.gov/archive/1999/08/23/professional/links/19990 823epid005.html
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Barrett's esophagus treatment costs dominated by medications Source: Reuters Medical News Date: August 18, 1999 http://www.reuters.gov/archive/1999/08/18/professional/links/19990 818econ001.html
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Cardiac intestinal metaplasia different from Barrett's esophagus Source: Reuters Medical News Date: March 19, 1999 http://www.reuters.gov/archive/1999/03/19/professional/links/19990 319clin008.html
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Argon beam plasma coagulation restores squamous lining in Barrett's esophagus Source: Reuters Medical News Date: November 16, 1998 http://www.reuters.gov/archive/1998/11/16/professional/links/19981 116clin009.html
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·
Barrett's esophagus linked to congenital varicella-zoster infection Source: Reuters Medical News Date: August 17, 1998 http://www.reuters.gov/archive/1998/08/17/professional/links/19980 817clin010.html
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Barrett's Esophagus-Related Adenocarcinoma: Better Estimates Are Needed Source: Reuters Medical News Date: March 06, 1997 http://www.reuters.gov/archive/1997/03/06/professional/links/19970 306epid001.html
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Characteristics Of Reflux Disease Predict Barrett's Esophagus Source: Reuters Medical News Date: January 20, 1997 http://www.reuters.gov/archive/1997/01/20/professional/links/19970 120clin006.html
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Phototherapy An Effective Approach To Management Of Barrett's Esophagus Source: Reuters Medical News Date: October 24, 1996 http://www.reuters.gov/archive/1996/10/24/professional/links/19961 024clin006.html
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Successful Reversal of Barrett's Esophagus Reported Source: Reuters Medical News Date: March 28, 1996 http://www.reuters.gov/archive/1996/03/28/professional/links/19960 328clin004.html
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Barrett's Esophagus Not A Risk Factor For Colorectal Cancer Source: Reuters Medical News Date: November 28, 1995 http://www.reuters.gov/archive/1995/11/28/professional/links/19951 128clin004.html
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Barrett's Esophagus Highlighted at ACG Meeting Source: Reuters Medical News Date: October 16, 1995 http://www.reuters.gov/archive/1995/10/16/professional/links/19951 016clin007.html
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The NIH Within MEDLINEplus, the NIH has made an agreement with the New York Times Syndicate, the AP News Service, and Reuters to deliver news that can be browsed by the public. Search news releases at http://www.nlm.nih.gov/medlineplus/alphanews_a.html. MEDLINEplus allows you to browse across an alphabetical index. Or you can search by date at http://www.nlm.nih.gov/medlineplus/newsbydate.html. Often, news items are indexed by MEDLINEplus within their search engine.
Business Wire Business Wire is similar to PR Newswire. To access this archive, simply go to http://www.businesswire.com. You can scan the news by industry category or company name.
Internet Wire Internet Wire is more focused on technology than the other wires. To access this site, go to http://www.internetwire.com and use the “Search Archive” option. Type in “Barrett’s esophagus” (or synonyms). As this service is oriented to technology, you may wish to search for press releases covering diagnostic procedures or tests that you may have read about. Search Engines Free-to-view news can also be found in the news section of your favorite search engines (see the health news page at Yahoo: http://dir.yahoo.com/Health/News_and_Media/, or use this Web site’s general news search page http://news.yahoo.com/. Type in “Barrett’s esophagus” (or synonyms). If you know the name of a company that is relevant to Barrett’s esophagus, you can go to any stock trading Web site (such as www.etrade.com) and search for the company name there. News items across various news sources are reported on indicated hyperlinks.
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BBC Covering news from a more European perspective, the British Broadcasting Corporation (BBC) allows the public free access to their news archive located at http://www.bbc.co.uk/. Search by “Barrett’s esophagus” (or synonyms).
Newsletters on Barrett’s Esophagus Given their focus on current and relevant developments, newsletters are often more useful to patients than academic articles. You can find newsletters using the Combined Health Information Database (CHID). You will need to use the “Detailed Search” option. To access CHID, go directly to the following hyperlink: http://chid.nih.gov/detail/detail.html. Your investigation must limit the search to “Newsletter” and “Barrett’s esophagus.” Go to the bottom of the search page where “You may refine your search by.” Select the dates and language that you prefer. For the format option, select “Newsletter.” By making these selections and typing in “Barrett’s esophagus” or synonyms into the “For these words:” box, you will only receive results on newsletters.
Newsletter Articles If you choose not to subscribe to a newsletter, you can nevertheless find references to newsletter articles. We recommend that you use the Combined Health Information Database, while limiting your search criteria to “newsletter articles.” Again, you will need to use the “Detailed Search” option. Go directly to the following hyperlink: http://chid.nih.gov/detail/detail.html. Go to the bottom of the search page where “You may refine your search by.” Select the dates and language that you prefer. For the format option, select “Newsletter Article.” By making these selections, and typing in “Barrett’s esophagus” (or synonyms) into the “For these words:” box, you will only receive results on newsletter articles. You should check back periodically with this database as it is updated every 3 months. The following is a typical result when searching for newsletter articles on Barrett’s esophagus: ·
Heartburn: Don't Ignore the Fire Source: Mayo Clinic Health Letter. 18(8): 1-3. August 2000.
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Contact: Available from Mayo Clinic Health Letter. Subscription Services, P.O. Box 53889, Boulder, CO 80322-3889. (800) 333-9037 or (303) 604-1465. Summary: This health newsletter article reviews heartburn, the burning sensation behind the breastbone, often accompanied by a sour taste in the back of the mouth. Heartburn is the result of stomach acid flowing up into the esophagus (gastroesophageal reflux). The article reviews the anatomy of the stomach and esophagus, and notes the factors that can result in heartburn, including simply overeating, or a weakened or abnormally relaxed esophageal sphincter. Frequent heartburn is called gastroesophageal reflux disease (GERD); people with GERD may also experience nausea, sore throat, hoarseness, wheezing, and a cough. Untreated, GERD can lead to inflammation of the esophagus (esophagitis) or to a precancerous condition called Barrett's esophagus. The article focuses on practical strategies to help prevent heartburn: control weight, avoid foods or beverages that can trigger heartburn, wear loose clothing, avoid lying down for 2 hours after eating, do not smoke, chew gum after meals, and drink adequate water when taking medications. Along with these lifestyle changes, nonprescription drugs that reduce painful stomach acid may relieve mild and occasional heartburn. These drugs include antacids and H2 blockers such as famotidine (Pepcid), nizatidine (Axid), ranitidine (Zantac), and cimetidine (Tagamet). When heartburn becomes frequent, readers are counseled to seek medical assistance. Diagnosis may include endoscopy and a pH monitoring test. After diagnosis, prescription medications may include stronger H2 blockers and proton pump inhibitors such as lansoprazole (Prevacid), omeprazole (Prilosec), pantoprazole (Protonix), and rabeprazole (Aciphex). Surgery may be indicated when drug therapy and lifestyle changes are not effective. One sidebar reports on new endoscopic treatments for heartburn; another sidebar cautions readers about the side effects of chronic heartburn. 1 figure.
Academic Periodicals covering Barrett’s Esophagus Academic periodicals can be a highly technical yet valuable source of information on Barrett’s esophagus. We have compiled the following list of periodicals known to publish articles relating to Barrett’s esophagus and which are currently indexed within the National Library of Medicine’s PubMed database (follow hyperlinks to view more information, summaries, etc., for each). In addition to these sources, to keep current on articles written on Barrett’s esophagus published by any of the periodicals listed below, you
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can simply follow the hyperlink indicated or go to the following Web site: www.ncbi.nlm.nih.gov/pubmed. Type the periodical’s name into the search box to find the latest studies published. If you want complete details about the historical contents of a periodical, you can also visit http://www.ncbi.nlm.nih.gov/entrez/jrbrowser.cgi. Here, type in the name of the journal or its abbreviation, and you will receive an index of published articles. At http://locatorplus.gov/ you can retrieve more indexing information on medical periodicals (e.g. the name of the publisher). Select the button “Search LOCATORplus.” Then type in the name of the journal and select the advanced search option “Journal Title Search.” The following is a sample of periodicals which publish articles on Barrett’s esophagus: ·
Diagnostic Cytopathology. (Diagn Cytopathol) http://www.ncbi.nlm.nih.gov/entrez/jrbrowser.cgi?field=0®exp=Di agnostic+Cytopathology&dispmax=20&dispstart=0
Vocabulary Builder Catheter: A tubular, flexible, surgical instrument for withdrawing fluids from (or introducing fluids into) a cavity of the body, especially one for introduction into the bladder through the urethra for the withdraw of urine. [EU]
Coagulation: 1. the process of clot formation. 2. in colloid chemistry, the solidification of a sol into a gelatinous mass; an alteration of a disperse phase or of a dissolved solid which causes the separation of the system into a liquid phase and an insoluble mass called the clot or curd. Coagulation is usually irreversible. 3. in surgery, the disruption of tissue by physical means to form an amorphous residuum, as in electrocoagulation and photocoagulation. [EU] Nausea: An unpleasant sensation, vaguely referred to the epigastrium and abdomen, and often culminating in vomiting. [EU] Nizatidine: A histamine H2 receptor antagonist with low toxicity that inhibits gastric acid secretion. The drug is used for the treatment of duodenal ulcers. [NIH]
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CHAPTER 8. PHYSICIAN GUIDELINES AND DATABASES Overview Doctors and medical researchers rely on a number of information sources to help patients with their conditions. Many will subscribe to journals or newsletters published by their professional associations or refer to specialized textbooks or clinical guides published for the medical profession. In this chapter, we focus on databases and Internet-based guidelines created or written for this professional audience.
NIH Guidelines For the more common diseases, The National Institutes of Health publish guidelines that are frequently consulted by physicians. Publications are typically written by one or more of the various NIH Institutes. For physician guidelines, commonly referred to as “clinical” or “professional” guidelines, you can visit the following Institutes: ·
Office of the Director (OD); guidelines consolidated across agencies available at http://www.nih.gov/health/consumer/conkey.htm
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National Institute of General Medical Sciences (NIGMS); fact sheets available at http://www.nigms.nih.gov/news/facts/
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National Library of Medicine (NLM); extensive encyclopedia (A.D.A.M., Inc.) with guidelines: http://www.nlm.nih.gov/medlineplus/healthtopics.html
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National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK); guidelines available at http://www.niddk.nih.gov/health/health.htm
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NIH Databases In addition to the various Institutes of Health that publish professional guidelines, the NIH has designed a number of databases for professionals.24 Physician-oriented resources provide a wide variety of information related to the biomedical and health sciences, both past and present. The format of these resources varies. Searchable databases, bibliographic citations, full text articles (when available), archival collections, and images are all available. The following are referenced by the National Library of Medicine:25 ·
Bioethics: Access to published literature on the ethical, legal and public policy issues surrounding healthcare and biomedical research. This information is provided in conjunction with the Kennedy Institute of Ethics located at Georgetown University, Washington, D.C.: http://www.nlm.nih.gov/databases/databases_bioethics.html
·
HIV/AIDS Resources: Describes various links and databases dedicated to HIV/AIDS research: http://www.nlm.nih.gov/pubs/factsheets/aidsinfs.html
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NLM Online Exhibitions: Describes “Exhibitions in the History of Medicine”: http://www.nlm.nih.gov/exhibition/exhibition.html. Additional resources for historical scholarship in medicine: http://www.nlm.nih.gov/hmd/hmd.html
·
Biotechnology Information: Access to public databases. The National Center for Biotechnology Information conducts research in computational biology, develops software tools for analyzing genome data, and disseminates biomedical information for the better understanding of molecular processes affecting human health and disease: http://www.ncbi.nlm.nih.gov/
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Population Information: The National Library of Medicine provides access to worldwide coverage of population, family planning, and related health issues, including family planning technology and programs, fertility, and population law and policy: http://www.nlm.nih.gov/databases/databases_population.html
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Cancer Information: Access to caner-oriented databases: http://www.nlm.nih.gov/databases/databases_cancer.html
Remember, for the general public, the National Library of Medicine recommends the databases referenced in MEDLINEplus (http://medlineplus.gov/ or http://www.nlm.nih.gov/medlineplus/databases.html). 25 See http://www.nlm.nih.gov/databases/databases.html. 24
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·
Profiles in Science: Offering the archival collections of prominent twentieth-century biomedical scientists to the public through modern digital technology: http://www.profiles.nlm.nih.gov/
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Chemical Information: Provides links to various chemical databases and references: http://sis.nlm.nih.gov/Chem/ChemMain.html
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Clinical Alerts: Reports the release of findings from the NIH-funded clinical trials where such release could significantly affect morbidity and mortality: http://www.nlm.nih.gov/databases/alerts/clinical_alerts.html
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Space Life Sciences: Provides links and information to space-based research (including NASA): http://www.nlm.nih.gov/databases/databases_space.html
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MEDLINE: Bibliographic database covering the fields of medicine, nursing, dentistry, veterinary medicine, the healthcare system, and the pre-clinical sciences: http://www.nlm.nih.gov/databases/databases_medline.html
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Toxicology and Environmental Health Information (TOXNET): Databases covering toxicology and environmental health: http://sis.nlm.nih.gov/Tox/ToxMain.html
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Visible Human Interface: Anatomically detailed, three-dimensional representations of normal male and female human bodies: http://www.nlm.nih.gov/research/visible/visible_human.html
While all of the above references may be of interest to physicians who study and treat Barrett’s esophagus, the following are particularly noteworthy.
The Combined Health Information Database A comprehensive source of information on clinical guidelines written for professionals is the Combined Health Information Database. You will need to limit your search to “Brochure/Pamphlet,” “Fact Sheet,” or “Information Package” and Barrett’s esophagus using the “Detailed Search” option. Go directly to the following hyperlink: http://chid.nih.gov/detail/detail.html. To find associations, use the drop boxes at the bottom of the search page where “You may refine your search by.” For the publication date, select “All Years,” select your preferred language, and the format option “Fact Sheet.” By making these selections and typing “Barrett’s esophagus” (or synonyms) into the “For these words:” box above, you will only receive results on fact sheets dealing with Barrett’s esophagus. The following is a sample result:
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·
American Pseudo-obstruction and Hirschsprung's Disease Society, Inc. (AHPS) Information Package Source: Andover, MA: American Pseudo-obstruction and Hirschsprung's Disease Society. 199x. [38 p.]. Contact: Available from American Pseudo-obstruction and Hirschsprung's Disease Society. 158 Pleasant Street, North Andover, MA 01845. (508) 685-4477. Fax (508) 685-4488. Price: Single copy free. Summary: This information packet is from the American Pseudoobstruction and Hirschsprung's Disease Society (APHS), an organization that addresses the needs of individuals affected by gastrointestinal (GI) motility disorders. The information packet includes an introductory brochure that describes the Society; a brochure for primary care physicians that describes pediatric gastroesophageal reflux disease (GERD); a guide for parents on GERD in infants and children; the text from a professional continuing education slide lecture program on GERD in children; sample issues of Gut Waves, the professional newsletter of the APHS; sample issues of The Messenger, the patient education newsletter of the organization; and fact sheets on chronic intestinal pseudo-obstruction and on gastroesophageal reflux in children. An order form for these materials is included. The materials are provided in a folder with the APHS logo on the front and the contact information for the Society inside. The NLM Gateway26
The NLM (National Library of Medicine) Gateway is a Web-based system that lets users search simultaneously in multiple retrieval systems at the U.S. National Library of Medicine (NLM). It allows users of NLM services to initiate searches from one Web interface, providing “one-stop searching” for many of NLM’s information resources or databases.27 One target audience for the Gateway is the Internet user who is new to NLM’s online resources and does not know what information is available or how best to search for it. This audience may include physicians and other healthcare providers, researchers, librarians, students, and, increasingly, patients, their families, and the public.28 To use the NLM Gateway, simply go to the search site at Adapted from NLM: http://gateway.nlm.nih.gov/gw/Cmd?Overview.x. The NLM Gateway is currently being developed by the Lister Hill National Center for Biomedical Communications (LHNCBC) at the National Library of Medicine (NLM) of the National Institutes of Health (NIH). 28 Other users may find the Gateway useful for an overall search of NLM’s information resources. Some searchers may locate what they need immediately, while others will utilize 26 27
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http://gateway.nlm.nih.gov/gw/Cmd. Type “Barrett’s esophagus” (or synonyms) into the search box and click “Search.” The results will be presented in a tabular form, indicating the number of references in each database category. Results Summary Category Items Found Journal Articles 343118 Books / Periodicals / Audio Visual 2561 Consumer Health 292 Meeting Abstracts 3093 Other Collections 100 Total 349164
HSTAT29 HSTAT is a free, Web-based resource that provides access to full-text documents used in healthcare decision-making.30 HSTAT’s audience includes healthcare providers, health service researchers, policy makers, insurance companies, consumers, and the information professionals who serve these groups. HSTAT provides access to a wide variety of publications, including clinical practice guidelines, quick-reference guides for clinicians, consumer health brochures, evidence reports and technology assessments from the Agency for Healthcare Research and Quality (AHRQ), as well as AHRQ’s Put Prevention Into Practice.31 Simply search by “Barrett’s esophagus” (or synonyms) at the following Web site: http://text.nlm.nih.gov. the Gateway as an adjunct tool to other NLM search services such as PubMed® and MEDLINEplus®. The Gateway connects users with multiple NLM retrieval systems while also providing a search interface for its own collections. These collections include various types of information that do not logically belong in PubMed, LOCATORplus, or other established NLM retrieval systems (e.g., meeting announcements and pre-1966 journal citations). The Gateway will provide access to the information found in an increasing number of NLM retrieval systems in several phases. 29 Adapted from HSTAT: http://www.nlm.nih.gov/pubs/factsheets/hstat.html. 30 The HSTAT URL is http://hstat.nlm.nih.gov/. 31 Other important documents in HSTAT include: the National Institutes of Health (NIH) Consensus Conference Reports and Technology Assessment Reports; the HIV/AIDS Treatment Information Service (ATIS) resource documents; the Substance Abuse and Mental Health Services Administration’s Center for Substance Abuse Treatment (SAMHSA/CSAT) Treatment Improvement Protocols (TIP) and Center for Substance Abuse Prevention (SAMHSA/CSAP) Prevention Enhancement Protocols System (PEPS); the Public Health Service (PHS) Preventive Services Task Force’s Guide to Clinical Preventive Services; the
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Coffee Break: Tutorials for Biologists32 Some patients may wish to have access to a general healthcare site that takes a scientific view of the news and covers recent breakthroughs in biology that may one day assist physicians in developing treatments. To this end, we recommend “Coffee Break,” a collection of short reports on recent biological discoveries. Each report incorporates interactive tutorials that demonstrate how bioinformatics tools are used as a part of the research process. Currently, all Coffee Breaks are written by NCBI staff.33 Each report is about 400 words and is usually based on a discovery reported in one or more articles from recently published, peer-reviewed literature.34 This site has new articles every few weeks, so it can be considered an online magazine of sorts, and intended for general background information. You can access the Coffee Break Web site at http://www.ncbi.nlm.nih.gov/Coffeebreak/.
Other Commercial Databases In addition to resources maintained by official agencies, other databases exist that are commercial ventures addressing medical professionals. Here are a few examples that may interest you: ·
CliniWeb International: Index and table of contents to selected clinical information on the Internet; see http://www.ohsu.edu/cliniweb/.
·
Image Engine: Multimedia electronic medical record system that integrates a wide range of digitized clinical images with textual data stored in the University of Pittsburgh Medical Center’s MARS electronic medical record system; see the following Web site: http://www.cml.upmc.edu/cml/imageengine/imageEngine.html.
·
Medical World Search: Searches full text from thousands of selected medical sites on the Internet; see http://www.mwsearch.com/.
independent, nonfederal Task Force on Community Services Guide to Community Preventive Services; and the Health Technology Advisory Committee (HTAC) of the Minnesota Health Care Commission (MHCC) health technology evaluations. 32 Adapted from http://www.ncbi.nlm.nih.gov/Coffeebreak/Archive/FAQ.html. 33 The figure that accompanies each article is frequently supplied by an expert external to NCBI, in which case the source of the figure is cited. The result is an interactive tutorial that tells a biological story. 34 After a brief introduction that sets the work described into a broader context, the report focuses on how a molecular understanding can provide explanations of observed biology and lead to therapies for diseases. Each vignette is accompanied by a figure and hypertext links that lead to a series of pages that interactively show how NCBI tools and resources are used in the research process.
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·
MedWeaver: Prototype system that allows users to search differential diagnoses for any list of signs and symptoms, to search medical literature, and to explore relevant Web sites; see http://www.med.virginia.edu/~wmd4n/medweaver.html.
·
Metaphrase: Middleware component intended for use by both caregivers and medical records personnel. It converts the informal language generally used by caregivers into terms from formal, controlled vocabularies; see the following Web site: http://www.lexical.com/Metaphrase.html.
The Genome Project and Barrett’s Esophagus With all the discussion in the press about the Human Genome Project, it is only natural that physicians, researchers, and patients want to know about how human genes relate to Barrett’s esophagus. In the following section, we will discuss databases and references used by physicians and scientists who work in this area. Online Mendelian Inheritance in Man (OMIM) The Online Mendelian Inheritance in Man (OMIM) database is a catalog of human genes and genetic disorders authored and edited by Dr. Victor A. McKusick and his colleagues at Johns Hopkins and elsewhere. OMIM was developed for the World Wide Web by the National Center for Biotechnology Information (NCBI).35 The database contains textual information, pictures, and reference information. It also contains copious links to NCBI’s Entrez database of MEDLINE articles and sequence information. Go to http://www.ncbi.nlm.nih.gov/Omim/searchomim.html to search the database. Type “Barrett’s esophagus” (or synonyms) in the search box, and click “Submit Search.” If too many results appear, you can narrow the search by adding the word “clinical.” Each report will have additional links to related research and databases. By following these links, especially the link titled “Database Links,” you will be exposed to numerous specialized databases that are largely used by the scientific community. These databases Adapted from http://www.ncbi.nlm.nih.gov/. Established in 1988 as a national resource for molecular biology information, NCBI creates public databases, conducts research in computational biology, develops software tools for analyzing genome data, and disseminates biomedical information--all for the better understanding of molecular processes affecting human health and disease.
35
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are overly technical and seldom used by the general public, but offer an abundance of information. The following is an example of the results you can obtain from the OMIM for Barrett’s esophagus: ·
Carney Complex, Type 1 Web site: http://www.ncbi.nlm.nih.gov/htbinpost/Omim/dispmim?160980
·
Hemochromatosis; Hfe Web site: http://www.ncbi.nlm.nih.gov/htbinpost/Omim/dispmim?235200
Genes and Disease (NCBI - Map) The Genes and Disease database is produced by the National Center for Biotechnology Information of the National Library of Medicine at the National Institutes of Health. Go to http://www.ncbi.nlm.nih.gov/disease/, and browse the system pages to have a full view of important conditions linked to human genes. Since this site is regularly updated, you may wish to re-visit it from time to time. The following systems and associated disorders are addressed: ·
Immune System: Fights invaders. Examples: Asthma, autoimmune polyglandular syndrome, Crohn’s disease, DiGeorge syndrome, familial Mediterranean fever, immunodeficiency with Hyper-IgM, severe combined immunodeficiency. Web site: http://www.ncbi.nlm.nih.gov/disease/Immune.html
·
Metabolism: Food and energy. Examples: Adreno-leukodystrophy, Atherosclerosis, Best disease, Gaucher disease, Glucose galactose malabsorption, Gyrate atrophy, Juvenile onset diabetes, Obesity, Paroxysmal nocturnal hemoglobinuria, Phenylketonuria, Refsum disease, Tangier disease, Tay-Sachs disease. Web site: http://www.ncbi.nlm.nih.gov/disease/Metabolism.html
·
Muscle and Bone: Movement and growth. Examples: Duchenne muscular dystrophy, Ellis-van Creveld syndrome, Marfan syndrome, myotonic dystrophy, spinal muscular atrophy. Web site: http://www.ncbi.nlm.nih.gov/disease/Muscle.html
·
Signals: Cellular messages. Examples: Ataxia telangiectasia, Baldness, Cockayne syndrome, Glaucoma, SRY: sex determination, Tuberous sclerosis, Waardenburg syndrome, Werner syndrome. Web site: http://www.ncbi.nlm.nih.gov/disease/Signals.html
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·
Transporters: Pumps and channels. Examples: Cystic Fibrosis, deafness, diastrophic dysplasia, Hemophilia A, long-QT syndrome, Menkes syndrome, Pendred syndrome, polycystic kidney disease, sickle cell anemia, Wilson’s disease, Zellweger syndrome. Web site: http://www.ncbi.nlm.nih.gov/disease/Transporters.html Entrez
Entrez is a search and retrieval system that integrates several linked databases at the National Center for Biotechnology Information (NCBI). These databases include nucleotide sequences, protein sequences, macromolecular structures, whole genomes, and MEDLINE through PubMed. Entrez provides access to the following databases: ·
PubMed: Biomedical literature (PubMed), Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed
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Nucleotide Sequence Database (Genbank): Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=Nucleotide
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Protein Sequence Database: Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=Protein
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Structure: Three-dimensional macromolecular structures, Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=Structure
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Genome: Complete genome assemblies, Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=Genome
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PopSet: Population study data sets, Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=Popset
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OMIM: Online Mendelian Inheritance in Man, Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=OMIM
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Taxonomy: Organisms in GenBank, Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=Taxonomy
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Books: Online books, Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=books
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ProbeSet: Gene Expression Omnibus (GEO), Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=geo
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3D Domains: Domains from Entrez Structure, Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=geo
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·
NCBI’s Protein Sequence Information Survey Results: Web site: http://www.ncbi.nlm.nih.gov/About/proteinsurvey/
To access the Entrez system at the National Center for Biotechnology Information, go to http://www.ncbi.nlm.nih.gov/entrez, and then select the database that you would like to search. The databases available are listed in the drop box next to “Search.” In the box next to “for,” enter “Barrett’s esophagus” (or synonyms) and click “Go.” Jablonski’s Multiple Congenital Anomaly/Mental Retardation (MCA/MR) Syndromes Database36 This online resource can be quite useful. It has been developed to facilitate the identification and differentiation of syndromic entities. Special attention is given to the type of information that is usually limited or completely omitted in existing reference sources due to space limitations of the printed form. At http://www.nlm.nih.gov/mesh/jablonski/syndrome_toc/toc_a.html you can also search across syndromes using an alphabetical index. You can also search at http://www.nlm.nih.gov/mesh/jablonski/syndrome_db.html. The Genome Database37 Established at Johns Hopkins University in Baltimore, Maryland in 1990, the Genome Database (GDB) is the official central repository for genomic mapping data resulting from the Human Genome Initiative. In the spring of 1999, the Bioinformatics Supercomputing Centre (BiSC) at the Hospital for Sick Children in Toronto, Ontario assumed the management of GDB. The Human Genome Initiative is a worldwide research effort focusing on structural analysis of human DNA to determine the location and sequence of the estimated 100,000 human genes. In support of this project, GDB stores and curates data generated by researchers worldwide who are engaged in the mapping effort of the Human Genome Project (HGP). GDB’s mission is to provide scientists with an encyclopedia of the human genome which is continually revised and updated to reflect the current state of scientific knowledge. Although GDB has historically focused on gene mapping, its Adapted from the National Library of Medicine: http://www.nlm.nih.gov/mesh/jablonski/about_syndrome.html. 37 Adapted from the Genome Database: http://gdbwww.gdb.org/gdb/aboutGDB.html#mission. 36
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focus will broaden as the Genome Project moves from mapping to sequence, and finally, to functional analysis. To access the GDB, simply go to the following hyperlink: http://www.gdb.org/. Search “All Biological Data” by “Keyword.” Type “Barrett’s esophagus” (or synonyms) into the search box, and review the results. If more than one word is used in the search box, then separate each one with the word “and” or “or” (using “or” might be useful when using synonyms). This database is extremely technical as it was created for specialists. The articles are the results which are the most accessible to nonprofessionals and often listed under the heading “Citations.” The contact names are also accessible to non-professionals.
Specialized References The following books are specialized references written for professionals interested in Barrett’s esophagus (sorted alphabetically by title, hyperlinks provide rankings, information, and reviews at Amazon.com): · Blackwell’s Primary Care Essentials: Gastointestinal Disease by David W. Hay; Paperback, 1st edition (December 15, 2001), Blackwell Science Inc; ISBN: 0632045035; http://www.amazon.com/exec/obidos/ASIN/0632045035/icongroupinterna · Gastrointestinal Problems by Martin S. Lipsky, M.D. (Editor), Richard Sadovsky, M.D. (Editor); Paperback - 194 pages, 1st edition (August 15, 2000), Lippincott, Williams & Wilkins Publishers; ISBN: 0781720540; http://www.amazon.com/exec/obidos/ASIN/0781720540/icongroupinterna · Rome II: The Functional Gastrointestinal Disorders by Douglas A. Drossman (Editor); Paperback - 800 pages, 2nd edition (March 1, 2000), Degnon Associates Inc.; ISBN: 0965683729; http://www.amazon.com/exec/obidos/ASIN/0965683729/icongroupinterna
Dissertations 101
CHAPTER 9. DISSERTATIONS ON BARRETT’S ESOPHAGUS Overview University researchers are active in studying almost all known diseases. The result of research is often published in the form of Doctoral or Master’s dissertations. You should understand, therefore, that applied diagnostic procedures and/or therapies can take many years to develop after the thesis that proposed the new technique or approach was written. In this chapter, we will give you a bibliography on recent dissertations relating to Barrett’s esophagus. You can read about these in more detail using the Internet or your local medical library. We will also provide you with information on how to use the Internet to stay current on dissertations.
Dissertations on Barrett’s Esophagus ProQuest Digital Dissertations is the largest archive of academic dissertations available. From this archive, we have compiled the following list covering dissertations devoted to Barrett’s esophagus. You will see that the information provided includes the dissertation’s title, its author, and the author’s institution. To read more about the following, simply use the Internet address indicated. The following covers recent dissertations dealing with Barrett’s esophagus: ·
Endoscopic and Morphologic Characterization of the Gastroesophageal Junction, with Special Emphasis on Barrett's Esophagus by Wallner, Bengt; Phd from Umea Universitet (sweden), 2001, 136 pages http://wwwlib.umi.com/dissertations/fullcit/f444049
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Keeping Current As previously mentioned, an effective way to stay current on dissertations dedicated to Barrett’s esophagus is to use the database called ProQuest Digital Dissertations via the Internet, located at the following Web address: http://wwwlib.umi.com/dissertations. The site allows you to freely access the last two years of citations and abstracts. Ask your medical librarian if the library has full and unlimited access to this database. From the library, you should be able to do more complete searches than with the limited 2-year access available to the general public.
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PART III. APPENDICES
ABOUT PART III Part III is a collection of appendices on general medical topics which may be of interest to patients with Barrett’s esophagus and related conditions.
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APPENDIX A. RESEARCHING YOUR MEDICATIONS Overview There are a number of sources available on new or existing medications which could be prescribed to patients with Barrett’s esophagus. While a number of hard copy or CD-Rom resources are available to patients and physicians for research purposes, a more flexible method is to use Internetbased databases. In this chapter, we will begin with a general overview of medications. We will then proceed to outline official recommendations on how you should view your medications. You may also want to research medications that you are currently taking for other conditions as they may interact with medications for Barrett’s esophagus. Research can give you information on the side effects, interactions, and limitations of prescription drugs used in the treatment of Barrett’s esophagus. Broadly speaking, there are two sources of information on approved medications: public sources and private sources. We will emphasize free-to-use public sources.
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Your Medications: The Basics38 The Agency for Health Care Research and Quality has published extremely useful guidelines on how you can best participate in the medication aspects of Barrett’s esophagus. Taking medicines is not always as simple as swallowing a pill. It can involve many steps and decisions each day. The AHCRQ recommends that patients with Barrett’s esophagus take part in treatment decisions. Do not be afraid to ask questions and talk about your concerns. By taking a moment to ask questions early, you may avoid problems later. Here are some points to cover each time a new medicine is prescribed: ·
Ask about all parts of your treatment, including diet changes, exercise, and medicines.
·
Ask about the risks and benefits of each medicine or other treatment you might receive.
·
Ask how often you or your doctor will check for side effects from a given medication.
Do not hesitate to ask what is important to you about your medicines. You may want a medicine with the fewest side effects, or the fewest doses to take each day. You may care most about cost, or how the medicine might affect how you live or work. Or, you may want the medicine your doctor believes will work the best. Telling your doctor will help him or her select the best treatment for you. Do not be afraid to “bother” your doctor with your concerns and questions about medications for Barrett’s esophagus. You can also talk to a nurse or a pharmacist. They can help you better understand your treatment plan. Feel free to bring a friend or family member with you when you visit your doctor. Talking over your options with someone you trust can help you make better choices, especially if you are not feeling well. Specifically, ask your doctor the following: ·
The name of the medicine and what it is supposed to do.
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How and when to take the medicine, how much to take, and for how long.
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What food, drinks, other medicines, or activities you should avoid while taking the medicine.
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What side effects the medicine may have, and what to do if they occur.
38
This section is adapted from AHCRQ: http://www.ahcpr.gov/consumer/ncpiebro.htm.
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·
If you can get a refill, and how often.
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About any terms or directions you do not understand.
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What to do if you miss a dose.
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If there is written information you can take home (most pharmacies have information sheets on your prescription medicines; some even offer large-print or Spanish versions).
Do not forget to tell your doctor about all the medicines you are currently taking (not just those for Barrett’s esophagus). This includes prescription medicines and the medicines that you buy over the counter. Then your doctor can avoid giving you a new medicine that may not work well with the medications you take now. When talking to your doctor, you may wish to prepare a list of medicines you currently take, the reason you take them, and how you take them. Be sure to include the following information for each: ·
Name of medicine
·
Reason taken
·
Dosage
·
Time(s) of day
Also include any over-the-counter medicines, such as: ·
Laxatives
·
Diet pills
·
Vitamins
·
Cold medicine
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Aspirin or other pain, headache, or fever medicine
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Cough medicine
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Allergy relief medicine
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Antacids
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Sleeping pills
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Others (include names)
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Learning More about Your Medications Because of historical investments by various organizations and the emergence of the Internet, it has become rather simple to learn about the medications your doctor has recommended for Barrett’s esophagus. One such source is the United States Pharmacopeia. In 1820, eleven physicians met in Washington, D.C. to establish the first compendium of standard drugs for the United States. They called this compendium the “U.S. Pharmacopeia (USP).” Today, the USP is a non-profit organization consisting of 800 volunteer scientists, eleven elected officials, and 400 representatives of state associations and colleges of medicine and pharmacy. The USP is located in Rockville, Maryland, and its home page is located at www.usp.org. The USP currently provides standards for over 3,700 medications. The resulting USP DIÒ Advice for the PatientÒ can be accessed through the National Library of Medicine of the National Institutes of Health. The database is partially derived from lists of federally approved medications in the Food and Drug Administration’s (FDA) Drug Approvals database.39 While the FDA database is rather large and difficult to navigate, the Phamacopeia is both user-friendly and free to use. It covers more than 9,000 prescription and over-the-counter medications. To access this database, simply type the following hyperlink into your Web browser: http://www.nlm.nih.gov/medlineplus/druginformation.html. To view examples of a given medication (brand names, category, description, preparation, proper use, precautions, side effects, etc.), simply follow the hyperlinks indicated within the United States Pharmacopoeia (USP). It is important to read the disclaimer by the USP (http://www.nlm.nih.gov/medlineplus/drugdisclaimer.html) before using the information provided.
Commercial Databases In addition to the medications listed in the USP above, a number of commercial sites are available by subscription to physicians and their institutions. You may be able to access these sources from your local medical library or your doctor’s office.
Though cumbersome, the FDA database can be freely browsed at the following site: www.fda.gov/cder/da/da.htm.
39
Researching Your Medications 109
Reuters Health Drug Database The Reuters Health Drug Database can be searched by keyword at the hyperlink: http://www.reutershealth.com/frame2/drug.html. The following medications are listed in the Reuters’ database as associated with Barrett’s esophagus (including those with contraindications):40 ·
Bethanechol Chloride http://www.reutershealth.com/atoz/html/Bethanechol_Chloride.htm
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Glycopyrrolate http://www.reutershealth.com/atoz/html/Glycopyrrolate.htm
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Magaldrate http://www.reutershealth.com/atoz/html/Magaldrate.htm
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Magnesium Oxide http://www.reutershealth.com/atoz/html/Magnesium_Oxide.htm
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Propantheline Bromide http://www.reutershealth.com/atoz/html/Propantheline_Bromide.htm
·
Sucralfate http://www.reutershealth.com/atoz/html/Sucralfate.htm
Mosby’s GenRx Mosby’s GenRx database (also available on CD-Rom and book format) covers 45,000 drug products including generics and international brands. It provides prescribing information, drug interactions, and patient information. Information can be obtained at the following hyperlink: http://www.genrx.com/Mosby/PhyGenRx/group.html. Physicians Desk Reference The Physicians Desk Reference database (also available in CD-Rom and book format) is a full-text drug database. The database is searchable by brand name, generic name or by indication. It features multiple drug interactions reports. Information can be obtained at the following hyperlink: http://physician.pdr.net/physician/templates/en/acl/psuser_t.htm.
40
Adapted from A to Z Drug Facts by Facts and Comparisons.
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Other Web Sites A number of additional Web sites discuss drug information. As an example, you may like to look at www.drugs.com which reproduces the information in the Pharmacopeia as well as commercial information. You may also want to consider the Web site of the Medical Letter, Inc. which allows users to download articles on various drugs and therapeutics for a nominal fee: http://www.medletter.com/.
Contraindications and Interactions (Hidden Dangers) Some of the medications mentioned in the previous discussions can be problematic for patients with Barrett’s esophagus--not because they are used in the treatment process, but because of contraindications, or side effects. Medications with contraindications are those that could react with drugs used to treat Barrett’s esophagus or potentially create deleterious side effects in patients with Barrett’s esophagus. You should ask your physician about any contraindications, especially as these might apply to other medications that you may be taking for common ailments. Drug-drug interactions occur when two or more drugs react with each other. This drug-drug interaction may cause you to experience an unexpected side effect. Drug interactions may make your medications less effective, cause unexpected side effects, or increase the action of a particular drug. Some drug interactions can even be harmful to you. Be sure to read the label every time you use a nonprescription or prescription drug, and take the time to learn about drug interactions. These precautions may be critical to your health. You can reduce the risk of potentially harmful drug interactions and side effects with a little bit of knowledge and common sense. Drug labels contain important information about ingredients, uses, warnings, and directions which you should take the time to read and understand. Labels also include warnings about possible drug interactions. Further, drug labels may change as new information becomes available. This is why it’s especially important to read the label every time you use a medication. When your doctor prescribes a new drug, discuss all over-thecounter and prescription medications, dietary supplements, vitamins, botanicals, minerals and herbals you take as well as the foods you eat. Ask your pharmacist for the package insert for each prescription drug you take.
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The package insert provides more information about potential drug interactions.
A Final Warning At some point, you may hear of alternative medications from friends, relatives, or in the news media. Advertisements may suggest that certain alternative drugs can produce positive results for patients with Barrett’s esophagus. Exercise caution--some of these drugs may have fraudulent claims, and others may actually hurt you. The Food and Drug Administration (FDA) is the official U.S. agency charged with discovering which medications are likely to improve the health of patients with Barrett’s esophagus. The FDA warns patients to watch out for41: ·
Secret formulas (real scientists share what they know)
·
Amazing breakthroughs or miracle cures (real breakthroughs don’t happen very often; when they do, real scientists do not call them amazing or miracles)
·
Quick, painless, or guaranteed cures
·
If it sounds too good to be true, it probably isn’t true.
If you have any questions about any kind of medical treatment, the FDA may have an office near you. Look for their number in the blue pages of the phone book. You can also contact the FDA through its toll-free number, 1888-INFO-FDA (1-888-463-6332), or on the World Wide Web at www.fda.gov.
General References In addition to the resources provided earlier in this chapter, the following general references describe medications (sorted alphabetically by title; hyperlinks provide rankings, information and reviews at Amazon.com): · Drug Development: Molecular Targets for Gi Diseases by Timothy S. Gaginella (Editor), Antonio Guglietta (Editor); Hardcover - 288 pages (December 1999), Humana Press; ISBN: 0896035891; http://www.amazon.com/exec/obidos/ASIN/0896035891/icongroupinterna
41
This section has been adapted from http://www.fda.gov/opacom/lowlit/medfraud.html.
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· Drug Therapy for Gastrointestinal and Liver Diseases by Michael J.G. Farthing, M.D. (Editor), Anne B. Ballinger (Editor); Hardcover - 346 pages, 1st edition (August 15, 2001), Martin Dunitz Ltd.; ISBN: 1853177334; http://www.amazon.com/exec/obidos/ASIN/1853177334/icongroupinterna · Immunopharmacology of the Gastrointestinal System (Handbook of Immunopharmacology) by John L. Wallace (Editor); Hardcover (October 1997), Academic Press; ISBN: 0127328602; http://www.amazon.com/exec/obidos/ASIN/0127328602/icongroupinterna · A Pharmacologic Approach to Gastrointestinal Disorders by James H. Lewis, M.D. (Editor); Hardcover – (February 1994), Lippincott, Williams & Wilkins; ISBN: 0683049704; http://www.amazon.com/exec/obidos/ASIN/0683049704/icongroupinterna
Vocabulary Builder The following vocabulary builder gives definitions of words used in this chapter that have not been defined in previous chapters: Glycopyrrolate: A muscarinic antagonist used as an antispasmodic, in some disorders of the gastrointestinal tract, and to reduce salivation with some anesthetics. [NIH] Pharmacist: A person trained to prepare and distribute medicines and to give information about them. [NIH] Pharmacologic: Pertaining to pharmacology or to the properties and reactions of drugs. [EU] Sucralfate: A basic aluminum complex of sulfated sucrose. It is advocated in the therapy of peptic, duodenal, and prepyloric ulcers, gastritis, reflux esophagitis, and other gastrointestinal irritations. It acts primarily at the ulcer site, where it has cytoprotective, pepsinostatic, antacid, and bile acidbinding properties. The drug is only slightly absorbed by the digestive mucosa, which explains the absence of systemic effects and toxicity. [NIH]
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APPENDIX B. RESEARCHING ALTERNATIVE MEDICINE Overview Complementary and alternative medicine (CAM) is one of the most contentious aspects of modern medical practice. You may have heard of these treatments on the radio or on television. Maybe you have seen articles written about these treatments in magazines, newspapers, or books. Perhaps your friends or doctor have mentioned alternatives. In this chapter, we will begin by giving you a broad perspective on complementary and alternative therapies. Next, we will introduce you to official information sources on CAM relating to Barrett’s esophagus. Finally, at the conclusion of this chapter, we will provide a list of readings on Barrett’s esophagus from various authors. We will begin, however, with the National Center for Complementary and Alternative Medicine’s (NCCAM) overview of complementary and alternative medicine.
What Is CAM?42 Complementary and alternative medicine (CAM) covers a broad range of healing philosophies, approaches, and therapies. Generally, it is defined as those treatments and healthcare practices which are not taught in medical schools, used in hospitals, or reimbursed by medical insurance companies. Many CAM therapies are termed “holistic,” which generally means that the healthcare practitioner considers the whole person, including physical, mental, emotional, and spiritual health. Some of these therapies are also known as “preventive,” which means that the practitioner educates and 42
Adapted from the NCCAM: http://nccam.nih.gov/nccam/fcp/faq/index.html#what-is.
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treats the person to prevent health problems from arising, rather than treating symptoms after problems have occurred. People use CAM treatments and therapies in a variety of ways. Therapies are used alone (often referred to as alternative), in combination with other alternative therapies, or in addition to conventional treatment (sometimes referred to as complementary). Complementary and alternative medicine, or “integrative medicine,” includes a broad range of healing philosophies, approaches, and therapies. Some approaches are consistent with physiological principles of Western medicine, while others constitute healing systems with non-Western origins. While some therapies are far outside the realm of accepted Western medical theory and practice, others are becoming established in mainstream medicine. Complementary and alternative therapies are used in an effort to prevent illness, reduce stress, prevent or reduce side effects and symptoms, or control or cure disease. Some commonly used methods of complementary or alternative therapy include mind/body control interventions such as visualization and relaxation, manual healing including acupressure and massage, homeopathy, vitamins or herbal products, and acupuncture.
What Are the Domains of Alternative Medicine?43 The list of CAM practices changes continually. The reason being is that these new practices and therapies are often proved to be safe and effective, and therefore become generally accepted as “mainstream” healthcare practices. Today, CAM practices may be grouped within five major domains: (1) alternative medical systems, (2) mind-body interventions, (3) biologicallybased treatments, (4) manipulative and body-based methods, and (5) energy therapies. The individual systems and treatments comprising these categories are too numerous to list in this sourcebook. Thus, only limited examples are provided within each. Alternative Medical Systems Alternative medical systems involve complete systems of theory and practice that have evolved independent of, and often prior to, conventional biomedical approaches. Many are traditional systems of medicine that are
43
Adapted from the NCCAM: http://nccam.nih.gov/nccam/fcp/classify/index.html.
Researching Alternative Medicine 115
practiced by individual cultures throughout the world, including a number of venerable Asian approaches. Traditional oriental medicine emphasizes the balance or disturbances of qi (pronounced chi) or vital energy in health and disease, respectively. Traditional oriental medicine consists of a group of techniques and methods including acupuncture, herbal medicine, oriental massage, and qi gong (a form of energy therapy). Acupuncture involves stimulating specific anatomic points in the body for therapeutic purposes, usually by puncturing the skin with a thin needle. Ayurveda is India’s traditional system of medicine. Ayurvedic medicine (meaning “science of life”) is a comprehensive system of medicine that places equal emphasis on body, mind, and spirit. Ayurveda strives to restore the innate harmony of the individual. Some of the primary Ayurvedic treatments include diet, exercise, meditation, herbs, massage, exposure to sunlight, and controlled breathing. Other traditional healing systems have been developed by the world’s indigenous populations. These populations include Native American, Aboriginal, African, Middle Eastern, Tibetan, and Central and South American cultures. Homeopathy and naturopathy are also examples of complete alternative medicine systems. Homeopathic medicine is an unconventional Western system that is based on the principle that “like cures like,” i.e., that the same substance that in large doses produces the symptoms of an illness, in very minute doses cures it. Homeopathic health practitioners believe that the more dilute the remedy, the greater its potency. Therefore, they use small doses of specially prepared plant extracts and minerals to stimulate the body’s defense mechanisms and healing processes in order to treat illness. Naturopathic medicine is based on the theory that disease is a manifestation of alterations in the processes by which the body naturally heals itself and emphasizes health restoration rather than disease treatment. Naturopathic physicians employ an array of healing practices, including the following: diet and clinical nutrition, homeopathy, acupuncture, herbal medicine, hydrotherapy (the use of water in a range of temperatures and methods of applications), spinal and soft-tissue manipulation, physical therapies (such as those involving electrical currents, ultrasound, and light), therapeutic counseling, and pharmacology.
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Mind-Body Interventions Mind-body interventions employ a variety of techniques designed to facilitate the mind’s capacity to affect bodily function and symptoms. Only a select group of mind-body interventions having well-documented theoretical foundations are considered CAM. For example, patient education and cognitive-behavioral approaches are now considered “mainstream.” On the other hand, complementary and alternative medicine includes meditation, certain uses of hypnosis, dance, music, and art therapy, as well as prayer and mental healing.
Biological-Based Therapies This category of CAM includes natural and biological-based practices, interventions, and products, many of which overlap with conventional medicine’s use of dietary supplements. This category includes herbal, special dietary, orthomolecular, and individual biological therapies. Herbal therapy employs an individual herb or a mixture of herbs for healing purposes. An herb is a plant or plant part that produces and contains chemical substances that act upon the body. Special diet therapies, such as those proposed by Drs. Atkins, Ornish, Pritikin, and Weil, are believed to prevent and/or control illness as well as promote health. Orthomolecular therapies aim to treat disease with varying concentrations of chemicals such as magnesium, melatonin, and mega-doses of vitamins. Biological therapies include, for example, the use of laetrile and shark cartilage to treat cancer and the use of bee pollen to treat autoimmune and inflammatory diseases.
Manipulative and Body-Based Methods This category includes methods that are based on manipulation and/or movement of the body. For example, chiropractors focus on the relationship between structure and function, primarily pertaining to the spine, and how that relationship affects the preservation and restoration of health. Chiropractors use manipulative therapy as an integral treatment tool. In contrast, osteopaths place particular emphasis on the musculoskeletal system and practice osteopathic manipulation. Osteopaths believe that all of the body’s systems work together and that disturbances in one system may have an impact upon function elsewhere in the body. Massage therapists manipulate the soft tissues of the body to normalize those tissues.
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Energy Therapies Energy therapies focus on energy fields originating within the body (biofields) or those from other sources (electromagnetic fields). Biofield therapies are intended to affect energy fields (the existence of which is not yet experimentally proven) that surround and penetrate the human body. Some forms of energy therapy manipulate biofields by applying pressure and/or manipulating the body by placing the hands in or through these fields. Examples include Qi gong, Reiki and Therapeutic Touch. Qi gong is a component of traditional oriental medicine that combines movement, meditation, and regulation of breathing to enhance the flow of vital energy (qi) in the body, improve blood circulation, and enhance immune function. Reiki, the Japanese word representing Universal Life Energy, is based on the belief that, by channeling spiritual energy through the practitioner, the spirit is healed and, in turn, heals the physical body. Therapeutic Touch is derived from the ancient technique of “laying-on of hands.” It is based on the premises that the therapist’s healing force affects the patient’s recovery and that healing is promoted when the body’s energies are in balance. By passing their hands over the patient, these healers identify energy imbalances. Bioelectromagnetic-based therapies involve the unconventional use of electromagnetic fields to treat illnesses or manage pain. These therapies are often used to treat asthma, cancer, and migraine headaches. Types of electromagnetic fields which are manipulated in these therapies include pulsed fields, magnetic fields, and alternating current or direct current fields.
Can Alternatives Affect My Treatment? A critical issue in pursuing complementary alternatives mentioned thus far is the risk that these might have undesirable interactions with your medical treatment. It becomes all the more important to speak with your doctor who can offer advice on the use of alternatives. Official sources confirm this view. Though written for women, we find that the National Women’s Health Information Center’s advice on pursuing alternative medicine is appropriate for patients of both genders and all ages.44
44
Adapted from http://www.4woman.gov/faq/alternative.htm.
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Is It Okay to Want Both Traditional and Alternative Medicine? Should you wish to explore non-traditional types of treatment, be sure to discuss all issues concerning treatments and therapies with your healthcare provider, whether a physician or practitioner of complementary and alternative medicine. Competent healthcare management requires knowledge of both conventional and alternative therapies you are taking for the practitioner to have a complete picture of your treatment plan. The decision to use complementary and alternative treatments is an important one. Consider before selecting an alternative therapy, the safety and effectiveness of the therapy or treatment, the expertise and qualifications of the healthcare practitioner, and the quality of delivery. These topics should be considered when selecting any practitioner or therapy.
Finding CAM References on Barrett’s Esophagus Having read the previous discussion, you may be wondering which complementary or alternative treatments might be appropriate for Barrett’s esophagus. For the remainder of this chapter, we will direct you to a number of official sources which can assist you in researching studies and publications. Some of these articles are rather technical, so some patience may be required. National Center for Complementary and Alternative Medicine The National Center for Complementary and Alternative Medicine (NCCAM) of the National Institutes of Health (http://nccam.nih.gov) has created a link to the National Library of Medicine’s databases to allow patients to search for articles that specifically relate to Barrett’s esophagus and complementary medicine. To search the database, go to the following Web site: www.nlm.nih.gov/nccam/camonpubmed.html. Select “CAM on PubMed.” Enter “Barrett’s esophagus” (or synonyms) into the search box. Click “Go.” The following references provide information on particular aspects of complementary and alternative medicine (CAM) that are related to Barrett’s esophagus: ·
Cytology of small-cell carcinoma arising in Barrett's esophagus. Author(s): Chen KT.
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Source: Diagnostic Cytopathology. 2000 September; 23(3): 180-2. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=10945905&dopt=Abstract ·
Experiences of a parent support group with the long-term consequences of esophageal atresia. Author(s): Schier F, Korn S, Michel E. Source: Journal of Pediatric Surgery. 2001 April; 36(4): 605-10. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=11283887&dopt=Abstract
·
Long-term survival of a patient with widespread metastases from Barrett's adenocarcinoma. Author(s): Mason GR, Micetich K, Aranha GV. Source: European Journal of Surgical Oncology : the Journal of the European Society of Surgical Oncology and the British Association of Surgical Oncology. 2001 August; 27(5): 509-10. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=11504525&dopt=Abstract
·
Malignant progression in Barrett's esophagus: pathology and molecular biology. Author(s): Mueller J, Werner M, Siewert JR. Source: Recent Results Cancer Res. 2000; 155: 29-41. Review. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=10693236&dopt=Abstract
·
Molecular biology of esophageal cancer. Author(s): D'Amico TA, Harpole DH Jr. Source: Chest Surg Clin N Am. 2000 August; 10(3): 451-69. Review. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=10967750&dopt=Abstract
Additional Web Resources A number of additional Web sites offer encyclopedic information covering CAM and related topics. The following is a representative sample: ·
Alternative Medicine Foundation, Inc.: http://www.herbmed.org/
·
AOL: http://search.aol.com/cat.adp?id=169&layer=&from=subcats
·
Chinese Medicine: http://www.newcenturynutrition.com/
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·
drkoop.comÒ: http://www.drkoop.com/InteractiveMedicine/IndexC.html
·
Family Village: http://www.familyvillage.wisc.edu/med_altn.htm
·
Google: http://directory.google.com/Top/Health/Alternative/
·
Healthnotes: http://www.thedacare.org/healthnotes/
·
Open Directory Project: http://dmoz.org/Health/Alternative/
·
TPN.com: http://www.tnp.com/
·
Yahoo.com: http://dir.yahoo.com/Health/Alternative_Medicine/
·
WebMDÒHealth: http://my.webmd.com/drugs_and_herbs
·
WellNet: http://www.wellnet.ca/herbsa-c.htm
·
WholeHealthMD.com: http://www.wholehealthmd.com/reflib/0,1529,,00.html
General References A good place to find general background information on CAM is the National Library of Medicine. It has prepared within the MEDLINEplus system an information topic page dedicated to complementary and alternative medicine. To access this page, go to the MEDLINEplus site at: www.nlm.nih.gov/medlineplus/alternativemedicine.html. This Web site provides a general overview of various topics and can lead to a number of general sources. The following additional references describe, in broad terms, alternative and complementary medicine (sorted alphabetically by title; hyperlinks provide rankings, information, and reviews at Amazon.com): · Gastrointestinal Disorders and Nutrition by Tonia Reinhard; Paperback 192 pages (January 24, 2002), McGraw-Hill Professional Publishing; ISBN: 0737303611; http://www.amazon.com/exec/obidos/ASIN/0737303611/icongroupinterna · Healthy Digestion the Natural Way: Preventing and Healing Heartburn, Constipation, Gas, Diarrhea, Inflammatory Bowel and Gallbladder Diseases, Ulcers, Irritable Bowel Syndrome, and More by D. Lindsey Berkson, et al; Paperback - 256 pages, 1st edition (February 2000), John Wiley & Sons; ISBN: 0471349623; http://www.amazon.com/exec/obidos/ASIN/0471349623/icongroupinterna · No More Heartburn: Stop the Pain in 30 Days--Naturally!: The Safe, Effective Way to Prevent and Heal Chronic Gastrointestinal Disorders by
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Sherry A. Rogers, M.D.; Paperback - 320 pages (February 2000), Kensington Publishing Corp.; ISBN: 1575665107; http://www.amazon.com/exec/obidos/ASIN/1575665107/icongroupinterna For additional information on complementary and alternative medicine, ask your doctor or write to: National Institutes of Health National Center for Complementary and Alternative Medicine Clearinghouse P. O. Box 8218 Silver Spring, MD 20907-8218
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APPENDIX C. RESEARCHING NUTRITION Overview Since the time of Hippocrates, doctors have understood the importance of diet and nutrition to patients’ health and well-being. Since then, they have accumulated an impressive archive of studies and knowledge dedicated to this subject. Based on their experience, doctors and healthcare providers may recommend particular dietary supplements to patients with Barrett’s esophagus. Any dietary recommendation is based on a patient’s age, body mass, gender, lifestyle, eating habits, food preferences, and health condition. It is therefore likely that different patients with Barrett’s esophagus may be given different recommendations. Some recommendations may be directly related to Barrett’s esophagus, while others may be more related to the patient’s general health. These recommendations, themselves, may differ from what official sources recommend for the average person. In this chapter we will begin by briefly reviewing the essentials of diet and nutrition that will broadly frame more detailed discussions of Barrett’s esophagus. We will then show you how to find studies dedicated specifically to nutrition and Barrett’s esophagus.
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Food and Nutrition: General Principles What Are Essential Foods? Food is generally viewed by official sources as consisting of six basic elements: (1) fluids, (2) carbohydrates, (3) protein, (4) fats, (5) vitamins, and (6) minerals. Consuming a combination of these elements is considered to be a healthy diet: ·
Fluids are essential to human life as 80-percent of the body is composed of water. Water is lost via urination, sweating, diarrhea, vomiting, diuretics (drugs that increase urination), caffeine, and physical exertion.
·
Carbohydrates are the main source for human energy (thermoregulation) and the bulk of typical diets. They are mostly classified as being either simple or complex. Simple carbohydrates include sugars which are often consumed in the form of cookies, candies, or cakes. Complex carbohydrates consist of starches and dietary fibers. Starches are consumed in the form of pastas, breads, potatoes, rice, and other foods. Soluble fibers can be eaten in the form of certain vegetables, fruits, oats, and legumes. Insoluble fibers include brown rice, whole grains, certain fruits, wheat bran and legumes.
·
Proteins are eaten to build and repair human tissues. Some foods that are high in protein are also high in fat and calories. Food sources for protein include nuts, meat, fish, cheese, and other dairy products.
·
Fats are consumed for both energy and the absorption of certain vitamins. There are many types of fats, with many general publications recommending the intake of unsaturated fats or those low in cholesterol.
Vitamins and minerals are fundamental to human health, growth, and, in some cases, disease prevention. Most are consumed in your diet (exceptions being vitamins K and D which are produced by intestinal bacteria and sunlight on the skin, respectively). Each vitamin and mineral plays a different role in health. The following outlines essential vitamins: ·
Vitamin A is important to the health of your eyes, hair, bones, and skin; sources of vitamin A include foods such as eggs, carrots, and cantaloupe.
·
Vitamin B1, also known as thiamine, is important for your nervous system and energy production; food sources for thiamine include meat, peas, fortified cereals, bread, and whole grains.
·
Vitamin B2, also known as riboflavin, is important for your nervous system and muscles, but is also involved in the release of proteins from
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nutrients; food sources for riboflavin include dairy products, leafy vegetables, meat, and eggs. ·
Vitamin B3, also known as niacin, is important for healthy skin and helps the body use energy; food sources for niacin include peas, peanuts, fish, and whole grains
·
Vitamin B6, also known as pyridoxine, is important for the regulation of cells in the nervous system and is vital for blood formation; food sources for pyridoxine include bananas, whole grains, meat, and fish.
·
Vitamin B12 is vital for a healthy nervous system and for the growth of red blood cells in bone marrow; food sources for vitamin B12 include yeast, milk, fish, eggs, and meat.
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Vitamin C allows the body’s immune system to fight various diseases, strengthens body tissue, and improves the body’s use of iron; food sources for vitamin C include a wide variety of fruits and vegetables.
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Vitamin D helps the body absorb calcium which strengthens bones and teeth; food sources for vitamin D include oily fish and dairy products.
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Vitamin E can help protect certain organs and tissues from various degenerative diseases; food sources for vitamin E include margarine, vegetables, eggs, and fish.
·
Vitamin K is essential for bone formation and blood clotting; common food sources for vitamin K include leafy green vegetables.
·
Folic Acid maintains healthy cells and blood and, when taken by a pregnant woman, can prevent her fetus from developing neural tube defects; food sources for folic acid include nuts, fortified breads, leafy green vegetables, and whole grains.
It should be noted that one can overdose on certain vitamins which become toxic if consumed in excess (e.g. vitamin A, D, E and K). Like vitamins, minerals are chemicals that are required by the body to remain in good health. Because the human body does not manufacture these chemicals internally, we obtain them from food and other dietary sources. The more important minerals include: ·
Calcium is needed for healthy bones, teeth, and muscles, but also helps the nervous system function; food sources for calcium include dry beans, peas, eggs, and dairy products.
·
Chromium is helpful in regulating sugar levels in blood; food sources for chromium include egg yolks, raw sugar, cheese, nuts, beets, whole grains, and meat.
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·
Fluoride is used by the body to help prevent tooth decay and to reinforce bone strength; sources of fluoride include drinking water and certain brands of toothpaste.
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Iodine helps regulate the body’s use of energy by synthesizing into the hormone thyroxine; food sources include leafy green vegetables, nuts, egg yolks, and red meat.
·
Iron helps maintain muscles and the formation of red blood cells and certain proteins; food sources for iron include meat, dairy products, eggs, and leafy green vegetables.
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Magnesium is important for the production of DNA, as well as for healthy teeth, bones, muscles, and nerves; food sources for magnesium include dried fruit, dark green vegetables, nuts, and seafood.
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Phosphorous is used by the body to work with calcium to form bones and teeth; food sources for phosphorous include eggs, meat, cereals, and dairy products.
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Selenium primarily helps maintain normal heart and liver functions; food sources for selenium include wholegrain cereals, fish, meat, and dairy products.
·
Zinc helps wounds heal, the formation of sperm, and encourage rapid growth and energy; food sources include dried beans, shellfish, eggs, and nuts.
The United States government periodically publishes recommended diets and consumption levels of the various elements of food. Again, your doctor may encourage deviations from the average official recommendation based on your specific condition. To learn more about basic dietary guidelines, visit the Web site: http://www.health.gov/dietaryguidelines/. Based on these guidelines, many foods are required to list the nutrition levels on the food’s packaging. Labeling Requirements are listed at the following site maintained by the Food and Drug Administration: http://www.cfsan.fda.gov/~dms/labcons.html. When interpreting these requirements, the government recommends that consumers become familiar with the following abbreviations before reading FDA literature:45 ·
DVs (Daily Values): A new dietary reference term that will appear on the food label. It is made up of two sets of references, DRVs and RDIs.
·
DRVs (Daily Reference Values): A set of dietary references that applies to fat, saturated fat, cholesterol, carbohydrate, protein, fiber, sodium, and potassium.
45
Adapted from the FDA: http://www.fda.gov/fdac/special/foodlabel/dvs.html.
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·
RDIs (Reference Daily Intakes): A set of dietary references based on the Recommended Dietary Allowances for essential vitamins and minerals and, in selected groups, protein. The name “RDI” replaces the term “U.S. RDA.”
·
RDAs (Recommended Dietary Allowances): A set of estimated nutrient allowances established by the National Academy of Sciences. It is updated periodically to reflect current scientific knowledge. What Are Dietary Supplements?46
Dietary supplements are widely available through many commercial sources, including health food stores, grocery stores, pharmacies, and by mail. Dietary supplements are provided in many forms including tablets, capsules, powders, gel-tabs, extracts, and liquids. Historically in the United States, the most prevalent type of dietary supplement was a multivitamin/mineral tablet or capsule that was available in pharmacies, either by prescription or “over the counter.” Supplements containing strictly herbal preparations were less widely available. Currently in the United States, a wide array of supplement products are available, including vitamin, mineral, other nutrients, and botanical supplements as well as ingredients and extracts of animal and plant origin. The Office of Dietary Supplements (ODS) of the National Institutes of Health is the official agency of the United States which has the expressed goal of acquiring “new knowledge to help prevent, detect, diagnose, and treat disease and disability, from the rarest genetic disorder to the common cold.”47 According to the ODS, dietary supplements can have an important impact on the prevention and management of disease and on the maintenance of health.48 The ODS notes that considerable research on the effects of dietary supplements has been conducted in Asia and Europe where This discussion has been adapted from the NIH: http://ods.od.nih.gov/whatare/whatare.html. 47 Contact: The Office of Dietary Supplements, National Institutes of Health, Building 31, Room 1B29, 31 Center Drive, MSC 2086, Bethesda, Maryland 20892-2086, Tel: (301) 435-2920, Fax: (301) 480-1845, E-mail:
[email protected]. 48 Adapted from http://ods.od.nih.gov/about/about.html. The Dietary Supplement Health and Education Act defines dietary supplements as “a product (other than tobacco) intended to supplement the diet that bears or contains one or more of the following dietary ingredients: a vitamin, mineral, amino acid, herb or other botanical; or a dietary substance for use to supplement the diet by increasing the total dietary intake; or a concentrate, metabolite, constituent, extract, or combination of any ingredient described above; and intended for ingestion in the form of a capsule, powder, softgel, or gelcap, and not represented as a conventional food or as a sole item of a meal or the diet.” 46
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the use of plant products, in particular, has a long tradition. However, the overwhelming majority of supplements have not been studied scientifically. To explore the role of dietary supplements in the improvement of health care, the ODS plans, organizes, and supports conferences, workshops, and symposia on scientific topics related to dietary supplements. The ODS often works in conjunction with other NIH Institutes and Centers, other government agencies, professional organizations, and public advocacy groups. To learn more about official information on dietary supplements, visit the ODS site at http://ods.od.nih.gov/whatare/whatare.html. Or contact: The Office of Dietary Supplements National Institutes of Health Building 31, Room 1B29 31 Center Drive, MSC 2086 Bethesda, Maryland 20892-2086 Tel: (301) 435-2920 Fax: (301) 480-1845 E-mail:
[email protected]
Finding Studies on Barrett’s Esophagus The NIH maintains an office dedicated to patient nutrition and diet. The National Institutes of Health’s Office of Dietary Supplements (ODS) offers a searchable bibliographic database called the IBIDS (International Bibliographic Information on Dietary Supplements). The IBIDS contains over 460,000 scientific citations and summaries about dietary supplements and nutrition as well as references to published international, scientific literature on dietary supplements such as vitamins, minerals, and botanicals.49 IBIDS is available to the public free of charge through the ODS Internet page: http://ods.od.nih.gov/databases/ibids.html. After entering the search area, you have three choices: (1) IBIDS Consumer Database, (2) Full IBIDS Database, or (3) Peer Reviewed Citations Only. We recommend that you start with the Consumer Database. While you may not find references for the topics that are of most interest to you, check back Adapted from http://ods.od.nih.gov. IBIDS is produced by the Office of Dietary Supplements (ODS) at the National Institutes of Health to assist the public, healthcare providers, educators, and researchers in locating credible, scientific information on dietary supplements. IBIDS was developed and will be maintained through an interagency partnership with the Food and Nutrition Information Center of the National Agricultural Library, U.S. Department of Agriculture.
49
Researching Nutrition 129
periodically as this database is frequently updated. More studies can be found by searching the Full IBIDS Database. Healthcare professionals and researchers generally use the third option, which lists peer-reviewed citations. In all cases, we suggest that you take advantage of the “Advanced Search” option that allows you to retrieve up to 100 fully explained references in a comprehensive format. Type “Barrett’s esophagus” (or synonyms) into the search box. To narrow the search, you can also select the “Title” field. The following information is typical of that found when using the “Full IBIDS Database” when searching using “Barrett’s esophagus” (or a synonym): ·
Clinical efficacy of sucralfate in reflux esophagitis. Comparison with cimetidine. Author(s): Academic Medical Centre, Amsterdam, The Netherlands. Source: Tytgat, G N Am-J-Med. 1987 September 28; 83(3B): 38-42 00029343
·
Clinical studies of sucralfate in reflux esophagitis. The European experience. Author(s): Department of Gastroenterology, Free University of Amsterdam, The Netherlands. Source: Hameeteman, W J-Clin-Gastroenterol. 1991; 13 Suppl 2S16-20 0192-0790
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Combination therapy of sucralfate and cimetidine, compared with sucralfate monotherapy, in patients with peptic reflux esophagitis. Author(s): Department of Gastroenterology, Academic Medical Centre, Free University Hospital, Amsterdam, The Netherlands. Source: Schotborgh, R H Hameeteman, W Dekker, W vd Boomgaard, D M Van Olffen, G H Schrijver, M Vosmaer, G D Tytgat, G N Am-J-Med. 1989 June 9; 86(6A): 77-80 0002-9343
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Comparison of the effect of sucralfate and ranitidine in reflux esophagitis. Author(s): Department of Gastroenterology, University Medical Clinic, Heidelberg, Federal Republic of Germany. Source: Simon, B Mueller, P Am-J-Med. 1987 September 28; 83(3B): 43-7 0002-9343
·
Mucosal protective effect of leminoprazole on reflux esophagitis induced in rats. Author(s): Department of Applied Pharmacology, Kyoto Pharmaceutical University, Japan.
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Source: Okabe, S Takinami, Y Iwata, K Yanagawa, T Jpn-J-Pharmacol. 1995 December; 69(4): 317-23 0021-5198 ·
Multicenter trial of sucralfate suspension for the treatment of reflux esophagitis. Author(s): Department of Medicine, University of North Carolina School of Medicine, Chapel Hill 27514. Source: Williams, R M Orlando, R C Bozymski, E M Readling, R D Castell, D O Roufail, W M Rick, G G Rubin, S E Sinar, D R Am-J-Med. 1987 September 28; 83(3B): 61-6 0002-9343
·
Oxidative damages are critical in pathogenesis of reflux esophagitis: implication of antioxidants in its treatment. Author(s): Dong-A Pharmaceutical Research Institute, Yongin, Kyunggido, South Korea. Source: Oh, T Y Lee, J S Ahn, B O Cho, H Kim, W B Kim, Y B Surh, Y J Cho, S W Hahm, K B Free-Radic-Biol-Med. 2001 April 15; 30(8): 905-15 0891-5849
·
Reflux esophagitis therapy: sucralfate versus ranitidine in a double blind multicenter trial. Author(s): Department of Surgery, Medical School, University of Witwatersand, Johannesburg, South Africa. Source: Bremner, C G Marks, I N Segal, I Simjee, A Am-J-Med. 1991 August 8; 91(2A): 119S-122S 0002-9343
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Sucralfate in the treatment of reflux esophagitis in adults: an update. Author(s): Department of Internal Medicine, Kreiskrankenhaus, Schwetzingen, FRG. Source: Simon, B Dammann, H G Muller, P Scand-J-Gastroenterol-Suppl. 1989; 15637-41 0085-5928
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Sucralfate in the treatment of reflux esophagitis in children. Preliminary results. Author(s): Department of Pediatrics, University Hospital Virgen de la Macarena, Seville, Spain. Source: Arguelles Martin, F Gonzalez Fernandez, F Gentles, M G Navarro Merino, M Scand-J-Gastroenterol-Suppl. 1989; 15643-7 0085-5928
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Sucralfate maintenance therapy in reflux esophagitis. Sucralfate Investigational Working Team. Author(s): Academic Medical Center, Amsterdam, The Netherlands. Source: Tytgat, G N Koelz, H R Vosmaer, G D Am-J-Gastroenterol. 1995 August; 90(8): 1233-7 0002-9270
·
Sucralfate therapy and reflux esophagitis: an overview. Author(s): University of North Carolina School of Medicine, Chapel Hill 27599.
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Source: Orlando, R C Am-J-Med. 1991 August 8; 91(2A): 123S-124S 00029343 ·
Sucralfate used as adjunctive therapy in patients with severe erosive peptic esophagitis resulting from gastroesophageal reflux. Author(s): University of South Alabama College of Medicine, Mobile. Source: Herrera, J L Shay, S S McCabe, M Peura, D A Johnson, L F Am-JGastroenterol. 1990 October; 85(10): 1335-8 0002-9270
·
Sucralfate versus alginate/antacid in the treatment of peptic esophagitis. Author(s): Gastro-Enterology Department, Hotel-Dieu, Lyon, France. Source: Evreux, M Am-J-Med. 1987 September 28; 83(3B): 48-50 0002-9343
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Sucralfate versus cimetidine in reflux esophagitis. A single-blind multicenter study. Author(s): Department of Gastro-enterology, Academic Medical Centre, Amsterdam, The Netherlands. Source: Hameeteman, W v d Boomgaard, D M Dekker, W Schrijver, M Wesdorp, I C Tytgat, G N J-Clin-Gastroenterol. 1987 August; 9(4): 390-4 0192-0790
·
Sucralfate versus cimetidine in the treatment of reflux esophagitis in children. Author(s): Department of Pediatrics, University Hospital Virgen de la Marcarena Seville, Spain. Source: Arguelles Martin, F Gonzalez Fernandez, F Gentles, M G Am-JMed. 1989 June 9; 86(6A): 73-6 0002-9343
·
Sucralfate versus cimetidine in the treatment of reflux esophagitis, with special reference to the esophageal motor function. Author(s): Department of Internal Medicine and Gastroenterology B, Frederiksberg University Hospital of Copenhagen, Denmark. Source: Jorgensen, F Elsborg, L Am-J-Med. 1991 August 8; 91(2A): 114S118S 0002-9343
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Sucralfate versus placebo in reflux esophagitis. A double-blind multicenter study. Author(s): Dept. of Medicine, Bollnas Hospital Sweden. Source: Carling, L Cronstedt, J Engqvist, A Kagevi, I Nystrom, B Svedberg, L E Thorhallsson, E Unge, P Wingren, P E Scand-JGastroenterol. 1988 November; 23(9): 1117-24 0036-5521
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Why does sucralfate improve healing in reflux esophagitis? The role of sucrose octasulfate. Author(s): Dept. of Medicine, University of North Carolina School of Medicine, Chapel Hill.
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Source: Orlando, R C Tobey, N A Scand-J-Gastroenterol-Suppl. 1990; 17317-21 0085-5928
Federal Resources on Nutrition In addition to the IBIDS, the United States Department of Health and Human Services (HHS) and the United States Department of Agriculture (USDA) provide many sources of information on general nutrition and health. Recommended resources include: ·
healthfinder®, HHS’s gateway to health information, including diet and nutrition: http://www.healthfinder.gov/scripts/SearchContext.asp?topic=238&page=0
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The United States Department of Agriculture’s Web site dedicated to nutrition information: www.nutrition.gov
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The Food and Drug Administration’s Web site for federal food safety information: www.foodsafety.gov
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The National Action Plan on Overweight and Obesity sponsored by the United States Surgeon General: http://www.surgeongeneral.gov/topics/obesity/
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The Center for Food Safety and Applied Nutrition has an Internet site sponsored by the Food and Drug Administration and the Department of Health and Human Services: http://vm.cfsan.fda.gov/
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Center for Nutrition Policy and Promotion sponsored by the United States Department of Agriculture: http://www.usda.gov/cnpp/
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Food and Nutrition Information Center, National Agricultural Library sponsored by the United States Department of Agriculture: http://www.nal.usda.gov/fnic/
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Food and Nutrition Service sponsored by the United States Department of Agriculture: http://www.fns.usda.gov/fns/
Additional Web Resources A number of additional Web sites offer encyclopedic information covering food and nutrition. The following is a representative sample: ·
AOL: http://search.aol.com/cat.adp?id=174&layer=&from=subcats
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Family Village: http://www.familyvillage.wisc.edu/med_nutrition.html
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·
Google: http://directory.google.com/Top/Health/Nutrition/
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Healthnotes: http://www.thedacare.org/healthnotes/
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Open Directory Project: http://dmoz.org/Health/Nutrition/
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Yahoo.com: http://dir.yahoo.com/Health/Nutrition/
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WebMDÒHealth: http://my.webmd.com/nutrition
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WholeHealthMD.com: http://www.wholehealthmd.com/reflib/0,1529,,00.html
Vocabulary Builder The following vocabulary builder defines words used in the references in this chapter that have not been defined in previous chapters: Bacteria: Unicellular prokaryotic microorganisms which generally possess rigid cell walls, multiply by cell division, and exhibit three principal forms: round or coccal, rodlike or bacillary, and spiral or spirochetal. [NIH] Capsules: Hard or soft soluble containers used for the oral administration of medicine. [NIH] Carbohydrate: An aldehyde or ketone derivative of a polyhydric alcohol, particularly of the pentahydric and hexahydric alcohols. They are so named because the hydrogen and oxygen are usually in the proportion to form water, (CH2O)n. The most important carbohydrates are the starches, sugars, celluloses, and gums. They are classified into mono-, di-, tri-, poly- and heterosaccharides. [EU] Cholesterol: The principal sterol of all higher animals, distributed in body tissues, especially the brain and spinal cord, and in animal fats and oils. [NIH] Degenerative: Undergoing degeneration : tending to degenerate; having the character of or involving degeneration; causing or tending to cause degeneration. [EU] Fats: One of the three main classes of foods and a source of energy in the body. Fats help the body use some vitamins and keep the skin healthy. They also serve as energy stores for the body. In food, there are two types of fats: saturated and unsaturated. [NIH] Iodine: A nonmetallic element of the halogen group that is represented by the atomic symbol I, atomic number 53, and atomic weight of 126.90. It is a nutritionally essential element, especially important in thyroid hormone synthesis. In solution, it has anti-infective properties and is used topically. [NIH]
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Neural: 1. pertaining to a nerve or to the nerves. 2. situated in the region of the spinal axis, as the neutral arch. [EU] Niacin: Water-soluble vitamin of the B complex occurring in various animal and plant tissues. Required by the body for the formation of coenzymes NAD and NADP. Has pellagra-curative, vasodilating, and antilipemic properties. [NIH] Overdose: 1. to administer an excessive dose. 2. an excessive dose. [EU] Pediatrics: A medical specialty concerned with maintaining health and providing medical care to children from birth to adolescence. [NIH] Potassium: An element that is in the alkali group of metals. It has an atomic symbol K, atomic number 19, and atomic weight 39.10. It is the chief cation in the intracellular fluid of muscle and other cells. Potassium ion is a strong electrolyte and it plays a significant role in the regulation of fluid volume and maintenance of the water-electrolyte balance. [NIH] Riboflavin: Nutritional factor found in milk, eggs, malted barley, liver, kidney, heart, and leafy vegetables. The richest natural source is yeast. It occurs in the free form only in the retina of the eye, in whey, and in urine; its principal forms in tissues and cells are as FMN and FAD. [NIH] Thyroxine: An amino acid of the thyroid gland which exerts a stimulating effect on thyroid metabolism. [NIH]
Finding Medical Libraries 135
APPENDIX D. FINDING MEDICAL LIBRARIES Overview At a medical library you can find medical texts and reference books, consumer health publications, specialty newspapers and magazines, as well as medical journals. In this Appendix, we show you how to quickly find a medical library in your area.
Preparation Before going to the library, highlight the references mentioned in this sourcebook that you find interesting. Focus on those items that are not available via the Internet, and ask the reference librarian for help with your search. He or she may know of additional resources that could be helpful to you. Most importantly, your local public library and medical libraries have Interlibrary Loan programs with the National Library of Medicine (NLM), one of the largest medical collections in the world. According to the NLM, most of the literature in the general and historical collections of the National Library of Medicine is available on interlibrary loan to any library. NLM’s interlibrary loan services are only available to libraries. If you would like to access NLM medical literature, then visit a library in your area that can request the publications for you.50
50
Adapted from the NLM: http://www.nlm.nih.gov/psd/cas/interlibrary.html.
136 Barrett’s Esophagus
Finding a Local Medical Library The quickest method to locate medical libraries is to use the Internet-based directory published by the National Network of Libraries of Medicine (NN/LM). This network includes 4626 members and affiliates that provide many services to librarians, health professionals, and the public. To find a library in your area, simply visit http://nnlm.gov/members/adv.html or call 1-800-338-7657.
Medical Libraries Open to the Public In addition to the NN/LM, the National Library of Medicine (NLM) lists a number of libraries that are generally open to the public and have reference facilities. The following is the NLM’s list plus hyperlinks to each library Web site. These Web pages can provide information on hours of operation and other restrictions. The list below is a small sample of libraries recommended by the National Library of Medicine (sorted alphabetically by name of the U.S. state or Canadian province where the library is located):51 ·
Alabama: Health InfoNet of Jefferson County (Jefferson County Library Cooperative, Lister Hill Library of the Health Sciences), http://www.uab.edu/infonet/
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Alabama: Richard M. Scrushy Library (American Sports Medicine Institute), http://www.asmi.org/LIBRARY.HTM
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Arizona: Samaritan Regional Medical Center: The Learning Center (Samaritan Health System, Phoenix, Arizona), http://www.samaritan.edu/library/bannerlibs.htm
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California: Kris Kelly Health Information Center (St. Joseph Health System), http://www.humboldt1.com/~kkhic/index.html
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California: Community Health Library of Los Gatos (Community Health Library of Los Gatos), http://www.healthlib.org/orgresources.html
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California: Consumer Health Program and Services (CHIPS) (County of Los Angeles Public Library, Los Angeles County Harbor-UCLA Medical Center Library) - Carson, CA, http://www.colapublib.org/services/chips.html
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California: Gateway Health Library (Sutter Gould Medical Foundation)
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California: Health Library (Stanford University Medical Center), http://www-med.stanford.edu/healthlibrary/
51
Abstracted from http://www.nlm.nih.gov/medlineplus/libraries.html.
Finding Medical Libraries 137
·
California: Patient Education Resource Center - Health Information and Resources (University of California, San Francisco), http://sfghdean.ucsf.edu/barnett/PERC/default.asp
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California: Redwood Health Library (Petaluma Health Care District), http://www.phcd.org/rdwdlib.html
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California: San José PlaneTree Health Library, http://planetreesanjose.org/
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California: Sutter Resource Library (Sutter Hospitals Foundation), http://go.sutterhealth.org/comm/resc-library/sac-resources.html
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California: University of California, Davis. Health Sciences Libraries
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California: ValleyCare Health Library & Ryan Comer Cancer Resource Center (ValleyCare Health System), http://www.valleycare.com/library.html
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California: Washington Community Health Resource Library (Washington Community Health Resource Library), http://www.healthlibrary.org/
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Colorado: William V. Gervasini Memorial Library (Exempla Healthcare), http://www.exempla.org/conslib.htm
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Connecticut: Hartford Hospital Health Science Libraries (Hartford Hospital), http://www.harthosp.org/library/
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Connecticut: Healthnet: Connecticut Consumer Health Information Center (University of Connecticut Health Center, Lyman Maynard Stowe Library), http://library.uchc.edu/departm/hnet/
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Connecticut: Waterbury Hospital Health Center Library (Waterbury Hospital), http://www.waterburyhospital.com/library/consumer.shtml
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Delaware: Consumer Health Library (Christiana Care Health System, Eugene du Pont Preventive Medicine & Rehabilitation Institute), http://www.christianacare.org/health_guide/health_guide_pmri_health _info.cfm
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Delaware: Lewis B. Flinn Library (Delaware Academy of Medicine), http://www.delamed.org/chls.html
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Georgia: Family Resource Library (Medical College of Georgia), http://cmc.mcg.edu/kids_families/fam_resources/fam_res_lib/frl.htm
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Georgia: Health Resource Center (Medical Center of Central Georgia), http://www.mccg.org/hrc/hrchome.asp
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Hawaii: Hawaii Medical Library: Consumer Health Information Service (Hawaii Medical Library), http://hml.org/CHIS/
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Idaho: DeArmond Consumer Health Library (Kootenai Medical Center), http://www.nicon.org/DeArmond/index.htm
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Illinois: Health Learning Center of Northwestern Memorial Hospital (Northwestern Memorial Hospital, Health Learning Center), http://www.nmh.org/health_info/hlc.html
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Illinois: Medical Library (OSF Saint Francis Medical Center), http://www.osfsaintfrancis.org/general/library/
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Kentucky: Medical Library - Services for Patients, Families, Students & the Public (Central Baptist Hospital), http://www.centralbap.com/education/community/library.htm
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Kentucky: University of Kentucky - Health Information Library (University of Kentucky, Chandler Medical Center, Health Information Library), http://www.mc.uky.edu/PatientEd/
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Louisiana: Alton Ochsner Medical Foundation Library (Alton Ochsner Medical Foundation), http://www.ochsner.org/library/
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Louisiana: Louisiana State University Health Sciences Center Medical Library-Shreveport, http://lib-sh.lsuhsc.edu/
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Maine: Franklin Memorial Hospital Medical Library (Franklin Memorial Hospital), http://www.fchn.org/fmh/lib.htm
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Maine: Gerrish-True Health Sciences Library (Central Maine Medical Center), http://www.cmmc.org/library/library.html
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Maine: Hadley Parrot Health Science Library (Eastern Maine Healthcare), http://www.emh.org/hll/hpl/guide.htm
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Maine: Maine Medical Center Library (Maine Medical Center), http://www.mmc.org/library/
·
Maine: Parkview Hospital, http://www.parkviewhospital.org/communit.htm#Library
·
Maine: Southern Maine Medical Center Health Sciences Library (Southern Maine Medical Center), http://www.smmc.org/services/service.php3?choice=10
·
Maine: Stephens Memorial Hospital Health Information Library (Western Maine Health), http://www.wmhcc.com/hil_frame.html
·
Manitoba, Canada: Consumer & Patient Health Information Service (University of Manitoba Libraries), http://www.umanitoba.ca/libraries/units/health/reference/chis.html
·
Manitoba, Canada: J.W. Crane Memorial Library (Deer Lodge Centre), http://www.deerlodge.mb.ca/library/libraryservices.shtml
Finding Medical Libraries 139
·
Maryland: Health Information Center at the Wheaton Regional Library (Montgomery County, Md., Dept. of Public Libraries, Wheaton Regional Library), http://www.mont.lib.md.us/healthinfo/hic.asp
·
Massachusetts: Baystate Medical Center Library (Baystate Health System), http://www.baystatehealth.com/1024/
·
Massachusetts: Boston University Medical Center Alumni Medical Library (Boston University Medical Center), http://medlibwww.bu.edu/library/lib.html
·
Massachusetts: Lowell General Hospital Health Sciences Library (Lowell General Hospital), http://www.lowellgeneral.org/library/HomePageLinks/WWW.htm
·
Massachusetts: Paul E. Woodard Health Sciences Library (New England Baptist Hospital), http://www.nebh.org/health_lib.asp
·
Massachusetts: St. Luke’s Hospital Health Sciences Library (St. Luke’s Hospital), http://www.southcoast.org/library/
·
Massachusetts: Treadwell Library Consumer Health Reference Center (Massachusetts General Hospital), http://www.mgh.harvard.edu/library/chrcindex.html
·
Massachusetts: UMass HealthNet (University of Massachusetts Medical School), http://healthnet.umassmed.edu/
·
Michigan: Botsford General Hospital Library - Consumer Health (Botsford General Hospital, Library & Internet Services), http://www.botsfordlibrary.org/consumer.htm
·
Michigan: Helen DeRoy Medical Library (Providence Hospital and Medical Centers), http://www.providence-hospital.org/library/
·
Michigan: Marquette General Hospital - Consumer Health Library (Marquette General Hospital, Health Information Center), http://www.mgh.org/center.html
·
Michigan: Patient Education Resouce Center - University of Michigan Cancer Center (University of Michigan Comprehensive Cancer Center), http://www.cancer.med.umich.edu/learn/leares.htm
·
Michigan: Sladen Library & Center for Health Information Resources Consumer Health Information, http://www.sladen.hfhs.org/library/consumer/index.html
·
Montana: Center for Health Information (St. Patrick Hospital and Health Sciences Center), http://www.saintpatrick.org/chi/librarydetail.php3?ID=41
140 Barrett’s Esophagus
·
National: Consumer Health Library Directory (Medical Library Association, Consumer and Patient Health Information Section), http://caphis.mlanet.org/directory/index.html
·
National: National Network of Libraries of Medicine (National Library of Medicine) - provides library services for health professionals in the United States who do not have access to a medical library, http://nnlm.gov/
·
National: NN/LM List of Libraries Serving the Public (National Network of Libraries of Medicine), http://nnlm.gov/members/
·
Nevada: Health Science Library, West Charleston Library (Las Vegas Clark County Library District), http://www.lvccld.org/special_collections/medical/index.htm
·
New Hampshire: Dartmouth Biomedical Libraries (Dartmouth College Library), http://www.dartmouth.edu/~biomed/resources.htmld/conshealth.htmld/
·
New Jersey: Consumer Health Library (Rahway Hospital), http://www.rahwayhospital.com/library.htm
·
New Jersey: Dr. Walter Phillips Health Sciences Library (Englewood Hospital and Medical Center), http://www.englewoodhospital.com/links/index.htm
·
New Jersey: Meland Foundation (Englewood Hospital and Medical Center), http://www.geocities.com/ResearchTriangle/9360/
·
New York: Choices in Health Information (New York Public Library) NLM Consumer Pilot Project participant, http://www.nypl.org/branch/health/links.html
·
New York: Health Information Center (Upstate Medical University, State University of New York), http://www.upstate.edu/library/hic/
·
New York: Health Sciences Library (Long Island Jewish Medical Center), http://www.lij.edu/library/library.html
·
New York: ViaHealth Medical Library (Rochester General Hospital), http://www.nyam.org/library/
·
Ohio: Consumer Health Library (Akron General Medical Center, Medical & Consumer Health Library), http://www.akrongeneral.org/hwlibrary.htm
·
Oklahoma: Saint Francis Health System Patient/Family Resource Center (Saint Francis Health System), http://www.sfhtulsa.com/patientfamilycenter/default.asp
Finding Medical Libraries 141
·
Oregon: Planetree Health Resource Center (Mid-Columbia Medical Center), http://www.mcmc.net/phrc/
·
Pennsylvania: Community Health Information Library (Milton S. Hershey Medical Center), http://www.hmc.psu.edu/commhealth/
·
Pennsylvania: Community Health Resource Library (Geisinger Medical Center), http://www.geisinger.edu/education/commlib.shtml
·
Pennsylvania: HealthInfo Library (Moses Taylor Hospital), http://www.mth.org/healthwellness.html
·
Pennsylvania: Hopwood Library (University of Pittsburgh, Health Sciences Library System), http://www.hsls.pitt.edu/chi/hhrcinfo.html
·
Pennsylvania: Koop Community Health Information Center (College of Physicians of Philadelphia), http://www.collphyphil.org/kooppg1.shtml
·
Pennsylvania: Learning Resources Center - Medical Library (Susquehanna Health System), http://www.shscares.org/services/lrc/index.asp
·
Pennsylvania: Medical Library (UPMC Health System), http://www.upmc.edu/passavant/library.htm
·
Quebec, Canada: Medical Library (Montreal General Hospital), http://ww2.mcgill.ca/mghlib/
·
South Dakota: Rapid City Regional Hospital - Health Information Center (Rapid City Regional Hospital, Health Information Center), http://www.rcrh.org/education/LibraryResourcesConsumers.htm
·
Texas: Houston HealthWays (Houston Academy of Medicine-Texas Medical Center Library), http://hhw.library.tmc.edu/
·
Texas: Matustik Family Resource Center (Cook Children’s Health Care System), http://www.cookchildrens.com/Matustik_Library.html
·
Washington: Community Health Library (Kittitas Valley Community Hospital), http://www.kvch.com/
·
Washington: Southwest Washington Medical Center Library (Southwest Washington Medical Center), http://www.swmedctr.com/Home/
Online Glossaries 143
APPENDIX E. YOUR RIGHTS AND INSURANCE Overview Any patient with Barrett’s esophagus faces a series of issues related more to the healthcare industry than to the medical condition itself. This appendix covers two important topics in this regard: your rights and responsibilities as a patient, and how to get the most out of your medical insurance plan.
Your Rights as a Patient The President’s Advisory Commission on Consumer Protection and Quality in the Healthcare Industry has created the following summary of your rights as a patient.52 Information Disclosure Consumers have the right to receive accurate, easily understood information. Some consumers require assistance in making informed decisions about health plans, health professionals, and healthcare facilities. Such information includes: ·
Health plans. Covered benefits, cost-sharing, and procedures for resolving complaints, licensure, certification, and accreditation status, comparable measures of quality and consumer satisfaction, provider network composition, the procedures that govern access to specialists and emergency services, and care management information.
52Adapted
from Consumer Bill of Rights and Responsibilities: http://www.hcqualitycommission.gov/press/cbor.html#head1.
144 Barrett’s Esophagus
·
Health professionals. Education, board certification, and recertification, years of practice, experience performing certain procedures, and comparable measures of quality and consumer satisfaction.
·
Healthcare facilities. Experience in performing certain procedures and services, accreditation status, comparable measures of quality, worker, and consumer satisfaction, and procedures for resolving complaints.
·
Consumer assistance programs. Programs must be carefully structured to promote consumer confidence and to work cooperatively with health plans, providers, payers, and regulators. Desirable characteristics of such programs are sponsorship that ensures accountability to the interests of consumers and stable, adequate funding.
Choice of Providers and Plans Consumers have the right to a choice of healthcare providers that is sufficient to ensure access to appropriate high-quality healthcare. To ensure such choice, the Commission recommends the following: ·
Provider network adequacy. All health plan networks should provide access to sufficient numbers and types of providers to assure that all covered services will be accessible without unreasonable delay -including access to emergency services 24 hours a day and 7 days a week. If a health plan has an insufficient number or type of providers to provide a covered benefit with the appropriate degree of specialization, the plan should ensure that the consumer obtains the benefit outside the network at no greater cost than if the benefit were obtained from participating providers.
·
Women’s health services. Women should be able to choose a qualified provider offered by a plan -- such as gynecologists, certified nurse midwives, and other qualified healthcare providers -- for the provision of covered care necessary to provide routine and preventative women’s healthcare services.
·
Access to specialists. Consumers with complex or serious medical conditions who require frequent specialty care should have direct access to a qualified specialist of their choice within a plan’s network of providers. Authorizations, when required, should be for an adequate number of direct access visits under an approved treatment plan.
·
Transitional care. Consumers who are undergoing a course of treatment for a chronic or disabling condition (or who are in the second or third trimester of a pregnancy) at the time they involuntarily change health
Online Glossaries 145
plans or at a time when a provider is terminated by a plan for other than cause should be able to continue seeing their current specialty providers for up to 90 days (or through completion of postpartum care) to allow for transition of care. ·
Choice of health plans. Public and private group purchasers should, wherever feasible, offer consumers a choice of high-quality health insurance plans.
Access to Emergency Services Consumers have the right to access emergency healthcare services when and where the need arises. Health plans should provide payment when a consumer presents to an emergency department with acute symptoms of sufficient severity--including severe pain--such that a “prudent layperson” could reasonably expect the absence of medical attention to result in placing that consumer’s health in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part.
Participation in Treatment Decisions Consumers have the right and responsibility to fully participate in all decisions related to their healthcare. Consumers who are unable to fully participate in treatment decisions have the right to be represented by parents, guardians, family members, or other conservators. Physicians and other health professionals should: ·
Provide patients with sufficient information and opportunity to decide among treatment options consistent with the informed consent process.
·
Discuss all treatment options with a patient in a culturally competent manner, including the option of no treatment at all.
·
Ensure that persons with disabilities have effective communications with members of the health system in making such decisions.
·
Discuss all current treatments a consumer may be undergoing.
·
Discuss all risks, nontreatment.
·
Give patients the opportunity to refuse treatment and to express preferences about future treatment decisions.
benefits,
and
consequences
to
treatment
or
146 Barrett’s Esophagus
·
Discuss the use of advance directives -- both living wills and durable powers of attorney for healthcare -- with patients and their designated family members.
·
Abide by the decisions made by their patients and/or their designated representatives consistent with the informed consent process.
Health plans, health providers, and healthcare facilities should: ·
Disclose to consumers factors -- such as methods of compensation, ownership of or interest in healthcare facilities, or matters of conscience -that could influence advice or treatment decisions.
·
Assure that provider contracts do not contain any so-called “gag clauses” or other contractual mechanisms that restrict healthcare providers’ ability to communicate with and advise patients about medically necessary treatment options.
·
Be prohibited from penalizing or seeking retribution against healthcare professionals or other health workers for advocating on behalf of their patients.
Respect and Nondiscrimination Consumers have the right to considerate, respectful care from all members of the healthcare industry at all times and under all circumstances. An environment of mutual respect is essential to maintain a quality healthcare system. To assure that right, the Commission recommends the following: ·
Consumers must not be discriminated against in the delivery of healthcare services consistent with the benefits covered in their policy, or as required by law, based on race, ethnicity, national origin, religion, sex, age, mental or physical disability, sexual orientation, genetic information, or source of payment.
·
Consumers eligible for coverage under the terms and conditions of a health plan or program, or as required by law, must not be discriminated against in marketing and enrollment practices based on race, ethnicity, national origin, religion, sex, age, mental or physical disability, sexual orientation, genetic information, or source of payment. Confidentiality of Health Information
Consumers have the right to communicate with healthcare providers in confidence and to have the confidentiality of their individually identifiable
Online Glossaries 147
healthcare information protected. Consumers also have the right to review and copy their own medical records and request amendments to their records. Complaints and Appeals Consumers have the right to a fair and efficient process for resolving differences with their health plans, healthcare providers, and the institutions that serve them, including a rigorous system of internal review and an independent system of external review. A free copy of the Patient’s Bill of Rights is available from the American Hospital Association.53
Patient Responsibilities Treatment is a two-way street between you and your healthcare providers. To underscore the importance of finance in modern healthcare as well as your responsibility for the financial aspects of your care, the President’s Advisory Commission on Consumer Protection and Quality in the Healthcare Industry has proposed that patients understand the following “Consumer Responsibilities.”54 In a healthcare system that protects consumers’ rights, it is reasonable to expect and encourage consumers to assume certain responsibilities. Greater individual involvement by the consumer in his or her care increases the likelihood of achieving the best outcome and helps support a quality-oriented, cost-conscious environment. Such responsibilities include: ·
Take responsibility for maximizing healthy habits such as exercising, not smoking, and eating a healthy diet.
·
Work collaboratively with healthcare providers in developing and carrying out agreed-upon treatment plans.
·
Disclose relevant information and clearly communicate wants and needs.
·
Use your health insurance plan’s internal complaint and appeal processes to address your concerns.
·
Avoid knowingly spreading disease.
To order your free copy of the Patient’s Bill of Rights, telephone 312-422-3000 or visit the American Hospital Association’s Web site: http://www.aha.org. Click on “Resource Center,” go to “Search” at bottom of page, and then type in “Patient’s Bill of Rights.” The Patient’s Bill of Rights is also available from Fax on Demand, at 312-422-2020, document number 471124. 54 Adapted from http://www.hcqualitycommission.gov/press/cbor.html#head1. 53
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·
Recognize the reality of risks, the limits of the medical science, and the human fallibility of the healthcare professional.
·
Be aware of a healthcare provider’s obligation to be reasonably efficient and equitable in providing care to other patients and the community.
·
Become knowledgeable about your health plan’s coverage and options (when available) including all covered benefits, limitations, and exclusions, rules regarding use of network providers, coverage and referral rules, appropriate processes to secure additional information, and the process to appeal coverage decisions.
·
Show respect for other patients and health workers.
·
Make a good-faith effort to meet financial obligations.
·
Abide by administrative and operational procedures of health plans, healthcare providers, and Government health benefit programs.
Choosing an Insurance Plan There are a number of official government agencies that help consumers understand their healthcare insurance choices.55 The U.S. Department of Labor, in particular, recommends ten ways to make your health benefits choices work best for you.56 1. Your options are important. There are many different types of health benefit plans. Find out which one your employer offers, then check out the plan, or plans, offered. Your employer’s human resource office, the health plan administrator, or your union can provide information to help you match your needs and preferences with the available plans. The more information you have, the better your healthcare decisions will be. 2. Reviewing the benefits available. Do the plans offered cover preventive care, well-baby care, vision or dental care? Are there deductibles? Answers to these questions can help determine the out-of-pocket expenses you may face. Matching your needs and those of your family members will result in the best possible benefits. Cheapest may not always be best. Your goal is high quality health benefits.
More information about quality across programs is provided at the following AHRQ Web site: http://www.ahrq.gov/consumer/qntascii/qnthplan.htm. 56 Adapted from the Department of Labor: http://www.dol.gov/dol/pwba/public/pubs/health/top10-text.html. 55
Online Glossaries 149
3. Look for quality. The quality of healthcare services varies, but quality can be measured. You should consider the quality of healthcare in deciding among the healthcare plans or options available to you. Not all health plans, doctors, hospitals and other providers give the highest quality care. Fortunately, there is quality information you can use right now to help you compare your healthcare choices. Find out how you can measure quality. Consult the U.S. Department of Health and Human Services publication “Your Guide to Choosing Quality Health Care” on the Internet at www.ahcpr.gov/consumer. 4. Your plan’s summary plan description (SPD) provides a wealth of information. Your health plan administrator can provide you with a copy of your plan’s SPD. It outlines your benefits and your legal rights under the Employee Retirement Income Security Act (ERISA), the federal law that protects your health benefits. It should contain information about the coverage of dependents, what services will require a co-pay, and the circumstances under which your employer can change or terminate a health benefits plan. Save the SPD and all other health plan brochures and documents, along with memos or correspondence from your employer relating to health benefits. 5. Assess your benefit coverage as your family status changes. Marriage, divorce, childbirth or adoption, and the death of a spouse are all life events that may signal a need to change your health benefits. You, your spouse and dependent children may be eligible for a special enrollment period under provisions of the Health Insurance Portability and Accountability Act (HIPAA). Even without life-changing events, the information provided by your employer should tell you how you can change benefits or switch plans, if more than one plan is offered. If your spouse’s employer also offers a health benefits package, consider coordinating both plans for maximum coverage. 6. Changing jobs and other life events can affect your health benefits. Under the Consolidated Omnibus Budget Reconciliation Act (COBRA), you, your covered spouse, and your dependent children may be eligible to purchase extended health coverage under your employer’s plan if you lose your job, change employers, get divorced, or upon occurrence of certain other events. Coverage can range from 18 to 36 months depending on your situation. COBRA applies to most employers with 20 or more workers and requires your plan to notify you of your rights. Most plans require eligible individuals to make their COBRA election within 60 days of the plan’s notice. Be sure to follow up with your plan sponsor if you don’t receive notice, and make sure you respond within the allotted time.
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7. HIPAA can also help if you are changing jobs, particularly if you have a medical condition. HIPAA generally limits pre-existing condition exclusions to a maximum of 12 months (18 months for late enrollees). HIPAA also requires this maximum period to be reduced by the length of time you had prior “creditable coverage.” You should receive a certificate documenting your prior creditable coverage from your old plan when coverage ends. 8. Plan for retirement. Before you retire, find out what health benefits, if any, extend to you and your spouse during your retirement years. Consult with your employer’s human resources office, your union, the plan administrator, and check your SPD. Make sure there is no conflicting information among these sources about the benefits you will receive or the circumstances under which they can change or be eliminated. With this information in hand, you can make other important choices, like finding out if you are eligible for Medicare and Medigap insurance coverage. 9. Know how to file an appeal if your health benefits claim is denied. Understand how your plan handles grievances and where to make appeals of the plan’s decisions. Keep records and copies of correspondence. Check your health benefits package and your SPD to determine who is responsible for handling problems with benefit claims. Contact PWBA for customer service assistance if you are unable to obtain a response to your complaint. 10. You can take steps to improve the quality of the healthcare and the health benefits you receive. Look for and use things like Quality Reports and Accreditation Reports whenever you can. Quality reports may contain consumer ratings -- how satisfied consumers are with the doctors in their plan, for instance-- and clinical performance measures -- how well a healthcare organization prevents and treats illness. Accreditation reports provide information on how accredited organizations meet national standards, and often include clinical performance measures. Look for these quality measures whenever possible. Consult “Your Guide to Choosing Quality Health Care” on the Internet at www.ahcpr.gov/consumer.
Medicare and Medicaid Illness strikes both rich and poor families. For low-income families, Medicaid is available to defer the costs of treatment. The Health Care Financing Administration (HCFA) administers Medicare, the nation’s largest health insurance program, which covers 39 million Americans. In the following pages, you will learn the basics about Medicare insurance as well as useful
Online Glossaries 151
contact information on how to find more in-depth information about Medicaid.57
Who is Eligible for Medicare? Generally, you are eligible for Medicare if you or your spouse worked for at least 10 years in Medicare-covered employment and you are 65 years old and a citizen or permanent resident of the United States. You might also qualify for coverage if you are under age 65 but have a disability or EndStage Renal disease (permanent kidney failure requiring dialysis or transplant). Here are some simple guidelines: You can get Part A at age 65 without having to pay premiums if: ·
You are already receiving retirement benefits from Social Security or the Railroad Retirement Board.
·
You are eligible to receive Social Security or Railroad benefits but have not yet filed for them.
·
You or your spouse had Medicare-covered government employment.
If you are under 65, you can get Part A without having to pay premiums if: ·
You have received Social Security or Railroad Retirement Board disability benefit for 24 months.
·
You are a kidney dialysis or kidney transplant patient.
Medicare has two parts: ·
Part A (Hospital Insurance). Most people do not have to pay for Part A.
·
Part B (Medical Insurance). Most people pay monthly for Part B. Part A (Hospital Insurance)
Helps Pay For: Inpatient hospital care, care in critical access hospitals (small facilities that give limited outpatient and inpatient services to people in rural areas) and skilled nursing facilities, hospice care, and some home healthcare.
This section has been adapted from the Official U.S. Site for Medicare Information: http://www.medicare.gov/Basics/Overview.asp.
57
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Cost: Most people get Part A automatically when they turn age 65. You do not have to pay a monthly payment called a premium for Part A because you or a spouse paid Medicare taxes while you were working. If you (or your spouse) did not pay Medicare taxes while you were working and you are age 65 or older, you still may be able to buy Part A. If you are not sure you have Part A, look on your red, white, and blue Medicare card. It will show “Hospital Part A” on the lower left corner of the card. You can also call the Social Security Administration toll free at 1-800-772-1213 or call your local Social Security office for more information about buying Part A. If you get benefits from the Railroad Retirement Board, call your local RRB office or 1-800-808-0772. For more information, call your Fiscal Intermediary about Part A bills and services. The phone number for the Fiscal Intermediary office in your area can be obtained from the following Web site: http://www.medicare.gov/Contacts/home.asp. Part B (Medical Insurance) Helps Pay For: Doctors, services, outpatient hospital care, and some other medical services that Part A does not cover, such as the services of physical and occupational therapists, and some home healthcare. Part B helps pay for covered services and supplies when they are medically necessary. Cost: As of 2001, you pay the Medicare Part B premium of $50.00 per month. In some cases this amount may be higher if you did not choose Part B when you first became eligible at age 65. The cost of Part B may go up 10% for each 12-month period that you were eligible for Part B but declined coverage, except in special cases. You will have to pay the extra 10% cost for the rest of your life. Enrolling in Part B is your choice. You can sign up for Part B anytime during a 7-month period that begins 3 months before you turn 65. Visit your local Social Security office, or call the Social Security Administration at 1-800-7721213 to sign up. If you choose to enroll in Part B, the premium is usually taken out of your monthly Social Security, Railroad Retirement, or Civil Service Retirement payment. If you do not receive any of the above payments, Medicare sends you a bill for your part B premium every 3 months. You should receive your Medicare premium bill in the mail by the 10th of the month. If you do not, call the Social Security Administration at 1800-772-1213, or your local Social Security office. If you get benefits from the Railroad Retirement Board, call your local RRB office or 1-800-808-0772. For more information, call your Medicare carrier about bills and services. The
Online Glossaries 153
phone number for the Medicare carrier in your area can be found at the following Web site: http://www.medicare.gov/Contacts/home.asp. You may have choices in how you get your healthcare including the Original Medicare Plan, Medicare Managed Care Plans (like HMOs), and Medicare Private Fee-for-Service Plans.
Medicaid Medicaid is a joint federal and state program that helps pay medical costs for some people with low incomes and limited resources. Medicaid programs vary from state to state. People on Medicaid may also get coverage for nursing home care and outpatient prescription drugs which are not covered by Medicare. You can find more information about Medicaid on the HCFA.gov Web site at http://www.hcfa.gov/medicaid/medicaid.htm. States also have programs that pay some or all of Medicare’s premiums and may also pay Medicare deductibles and coinsurance for certain people who have Medicare and a low income. To qualify, you must have: ·
Part A (Hospital Insurance),
·
Assets, such as bank accounts, stocks, and bonds that are not more than $4,000 for a single person, or $6,000 for a couple, and
·
A monthly income that is below certain limits.
For more information on these programs, look at the Medicare Savings Programs brochure, http://www.medicare.gov/Library/PDFNavigation/PDFInterim.asp?Langua ge=English&Type=Pub&PubID=10126. There are also Prescription Drug Assistance Programs available. Find information on these programs which offer discounts or free medications to individuals in need at http://www.medicare.gov/Prescription/Home.asp.
NORD’s Medication Assistance Programs Finally, the National Organization for Rare Disorders, Inc. (NORD) administers medication programs sponsored by humanitarian-minded pharmaceutical and biotechnology companies to help uninsured or underinsured individuals secure life-saving or life-sustaining drugs.58 NORD Adapted from NORD: http://www.rarediseases.org/cgibin/nord/progserv#patient?id=rPIzL9oD&mv_pc=30.
58
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programs ensure that certain vital drugs are available “to those individuals whose income is too high to qualify for Medicaid but too low to pay for their prescribed medications.” The program has standards for fairness, equity, and unbiased eligibility. It currently covers some 14 programs for nine pharmaceutical companies. NORD also offers early access programs for investigational new drugs (IND) under the approved “Treatment INDs” programs of the Food and Drug Administration (FDA). In these programs, a limited number of individuals can receive investigational drugs that have yet to be approved by the FDA. These programs are generally designed for rare diseases or disorders. For more information, visit www.rarediseases.org.
Additional Resources In addition to the references already listed in this chapter, you may need more information on health insurance, hospitals, or the healthcare system in general. The NIH has set up an excellent guidance Web site that addresses these and other issues. Topics include:59 ·
Health Insurance: http://www.nlm.nih.gov/medlineplus/healthinsurance.html
·
Health Statistics: http://www.nlm.nih.gov/medlineplus/healthstatistics.html
·
HMO and Managed Care: http://www.nlm.nih.gov/medlineplus/managedcare.html
·
Hospice Care: http://www.nlm.nih.gov/medlineplus/hospicecare.html
·
Medicaid: http://www.nlm.nih.gov/medlineplus/medicaid.html
·
Medicare: http://www.nlm.nih.gov/medlineplus/medicare.html
·
Nursing Homes and Long-term Care: http://www.nlm.nih.gov/medlineplus/nursinghomes.html
·
Patient’s Rights, Confidentiality, Informed Consent, Ombudsman Programs, Privacy and Patient Issues: http://www.nlm.nih.gov/medlineplus/patientissues.html
You can access this information at: http://www.nlm.nih.gov/medlineplus/healthsystem.html.
59
Online Glossaries 155
ONLINE GLOSSARIES The Internet provides access to a number of free-to-use medical dictionaries and glossaries. The National Library of Medicine has compiled the following list of online dictionaries: ·
ADAM Medical Encyclopedia (A.D.A.M., Inc.), comprehensive medical reference: http://www.nlm.nih.gov/medlineplus/encyclopedia.html
·
MedicineNet.com Medical Dictionary (MedicineNet, Inc.): http://www.medterms.com/Script/Main/hp.asp
·
Merriam-Webster Medical Dictionary (Inteli-Health, Inc.): http://www.intelihealth.com/IH/
·
Multilingual Glossary of Technical and Popular Medical Terms in Eight European Languages (European Commission) - Danish, Dutch, English, French, German, Italian, Portuguese, and Spanish: http://allserv.rug.ac.be/~rvdstich/eugloss/welcome.html
·
On-line Medical Dictionary (CancerWEB): http://www.graylab.ac.uk/omd/
·
Technology Glossary (National Library of Medicine) - Health Care Technology: http://www.nlm.nih.gov/nichsr/ta101/ta10108.htm
·
Terms and Definitions (Office of Rare Diseases): http://rarediseases.info.nih.gov/ord/glossary_a-e.html
Beyond these, MEDLINEplus contains a very user-friendly encyclopedia covering every aspect of medicine (licensed from A.D.A.M., Inc.). The ADAM Medical Encyclopedia Web site address is http://www.nlm.nih.gov/medlineplus/encyclopedia.html. ADAM is also available on commercial Web sites such as Web MD (http://my.webmd.com/adam/asset/adam_disease_articles/a_to_z/a) and drkoop.com (http://www.drkoop.com/). Topics of interest can be researched by using keywords before continuing elsewhere, as these basic definitions and concepts will be useful in more advanced areas of research. You may choose to print various pages specifically relating to Barrett’s esophagus and keep them on file. The NIH, in particular, suggests that patients with Barrett’s esophagus visit the following Web sites in the ADAM Medical Encyclopedia:
156 Barrett’s Esophagus
·
Basic Guidelines for Barrett’s Esophagus Barrett's esophagus Web site: http://www.nlm.nih.gov/medlineplus/ency/article/001143.htm GERD Web site: http://www.nlm.nih.gov/medlineplus/ency/article/000265.htm Peptic ulcer Web site: http://www.nlm.nih.gov/medlineplus/ency/article/000206.htm
·
Signs & Symptoms for Barrett’s Esophagus Chest pain Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003079.htm Difficulty swallowing Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003115.htm Dysphagia Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003115.htm Heartburn Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003114.htm Melena Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003130.htm
·
Diagnostics and Tests for Barrett’s Esophagus Biopsy Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003416.htm
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Endoscopy Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003338.htm Gastric acid Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003883.htm ·
Nutrition for Barrett’s Esophagus Caffeine Web site: http://www.nlm.nih.gov/medlineplus/ency/article/002445.htm Fat Web site: http://www.nlm.nih.gov/medlineplus/ency/article/002468.htm
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Background Topics for Barrett’s Esophagus Asymptomatic Web site: http://www.nlm.nih.gov/medlineplus/ency/article/002217.htm Relieved by Web site: http://www.nlm.nih.gov/medlineplus/ency/article/002288.htm Weight reduction Web site: http://www.nlm.nih.gov/medlineplus/ency/article/001940.htm
Online Dictionary Directories The following are additional online directories compiled by the National Library of Medicine, including a number of specialized medical dictionaries and glossaries: ·
Medical Dictionaries: Medical & Biological (World Health Organization): http://www.who.int/hlt/virtuallibrary/English/diction.htm#Medical
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MEL-Michigan Electronic Library List of Online Health and Medical Dictionaries (Michigan Electronic Library): http://mel.lib.mi.us/health/health-dictionaries.html
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Patient Education: Glossaries (DMOZ Open Directory Project): http://dmoz.org/Health/Education/Patient_Education/Glossaries/
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Web of Online Dictionaries (Bucknell University): http://www.yourdictionary.com/diction5.html#medicine
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BARRETT’S ESOPHAGUS GLOSSARY The following is a complete glossary of terms used in this sourcebook. The definitions are derived from official public sources including the National Institutes of Health [NIH] and the European Union [EU]. After this glossary, we list a number of additional hardbound and electronic glossaries and dictionaries that you may wish to consult. Aberrant: Wandering or deviating from the usual or normal course. [EU] Adenocarcinoma: organization. [NIH]
A malignant epithelial tumor with a glandular
Algorithms: A procedure consisting of a sequence of algebraic formulas and/or logical steps to calculate or determine a given task. [NIH] Alimentary: Pertaining to food or nutritive material, or to the organs of digestion. [EU] Antibiotic: A chemical substance produced by a microorganism which has the capacity, in dilute solutions, to inhibit the growth of or to kill other microorganisms. Antibiotics that are sufficiently nontoxic to the host are used as chemotherapeutic agents in the treatment of infectious diseases of man, animals and plants. [EU] Antioxidant: One of many widely used synthetic or natural substances added to a product to prevent or delay its deterioration by action of oxygen in the air. Rubber, paints, vegetable oils, and prepared foods commonly contain antioxidants. [EU] Artery: A large blood vessel that carries blood from the heart to other parts of the body. Arteries are thicker and have walls that are stronger and more elastic than the walls of veins. [NIH] Aspiration: The act of inhaling. [EU] Assay: Determination of the amount of a particular constituent of a mixture, or of the biological or pharmacological potency of a drug. [EU] Asymptomatic: No symptoms; no clear sign of disease present. [NIH] Bacteria: Unicellular prokaryotic microorganisms which generally possess rigid cell walls, multiply by cell division, and exhibit three principal forms: round or coccal, rodlike or bacillary, and spiral or spirochetal. [NIH] Barium: An element of the alkaline earth group of metals. It has an atomic symbol Ba, atomic number 56, and atomic weight 138. All of its acid-soluble salts are poisonous. [NIH] Bile: An emulsifying agent produced in the liver and secreted into the
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duodenum. Its composition includes bile acids and salts, cholesterol, and electrolytes. It aids digestion of fats in the duodenum. [NIH] Biopsy: The removal and examination, usually microscopic, of tissue from the living body, performed to establish precise diagnosis. [EU] Capsules: Hard or soft soluble containers used for the oral administration of medicine. [NIH] Carbohydrate: An aldehyde or ketone derivative of a polyhydric alcohol, particularly of the pentahydric and hexahydric alcohols. They are so named because the hydrogen and oxygen are usually in the proportion to form water, (CH2O)n. The most important carbohydrates are the starches, sugars, celluloses, and gums. They are classified into mono-, di-, tri-, poly- and heterosaccharides. [EU] Carcinogenic: Producing carcinoma. [EU] Cardia: That part of the stomach surrounded by the esophagogastric junction, characterized by the lack of acid-forming cells. [NIH] Cardiac: Pertaining to the heart. [EU] Catheter: A tubular, flexible, surgical instrument for withdrawing fluids from (or introducing fluids into) a cavity of the body, especially one for introduction into the bladder through the urethra for the withdraw of urine. [EU]
Cervical: Pertaining to the neck, or to the neck of any organ or structure. [EU] Chemotherapy: The treatment of disease by means of chemicals that have a specific toxic effect upon the disease - producing microorganisms or that selectively destroy cancerous tissue. [EU] Chest Pain: Pressure, burning, or numbness in the chest. [NIH] Cholesterol: The principal sterol of all higher animals, distributed in body tissues, especially the brain and spinal cord, and in animal fats and oils. [NIH] Chromosomal: Pertaining to chromosomes. [EU] Cimetidine: A histamine congener, it competitively inhibits histamine binding to H2 receptors. Cimetidine has a range of pharmacological actions. It inhibits gastric acid secretion, as well as pepsin and gastrin output. It also blocks the activity of cytochrome P-450. [NIH] Coagulation: 1. the process of clot formation. 2. in colloid chemistry, the solidification of a sol into a gelatinous mass; an alteration of a disperse phase or of a dissolved solid which causes the separation of the system into a liquid phase and an insoluble mass called the clot or curd. Coagulation is usually irreversible. 3. in surgery, the disruption of tissue by physical means to form an amorphous residuum, as in electrocoagulation and photocoagulation. [EU] Colitis: Inflammation of the colon. [EU]
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Colonoscopy: Endoscopic examination, therapy or surgery of the luminal surface of the colon. [NIH] Crowding: Behavior with respect to an excessive number of individuals, human or animal, in relation to available space. [NIH] Degenerative: Undergoing degeneration : tending to degenerate; having the character of or involving degeneration; causing or tending to cause degeneration. [EU] Dermatitis: Inflammation of the skin. [EU] Diarrhea: Passage of excessively liquid or excessively frequent stools. [NIH] Dietetics: The study and regulation of the diet. [NIH] Diverticulum: A pathological condition manifested as a pouch or sac opening from a tubular or sacular organ. [NIH] Dysphagia: Difficulty in swallowing. [EU] Dysplasia: Abnormality of development; in pathology, alteration in size, shape, and organization of adult cells. [EU] Ectopic: Pertaining to or characterized by ectopia. [EU] Electrolyte: A substance that dissociates into ions when fused or in solution, and thus becomes capable of conducting electricity; an ionic solute. [EU] Endocrinology: A subspecialty of internal medicine concerned with the metabolism, physiology, and disorders of the endocrine system. [NIH] Endoscopy: Visual inspection of any cavity of the body by means of an endoscope. [EU] Enteritis: Inflammation of the intestine, applied chiefly to inflammation of the small intestine; see also enterocolitis. [EU] Epidemic: Occurring suddenly in numbers clearly in excess of normal expectancy; said especially of infectious diseases but applied also to any disease, injury, or other health-related event occurring in such outbreaks. [EU] Epidemiological: Relating to, or involving epidemiology. [EU] Epithelium: The covering of internal and external surfaces of the body, including the lining of vessels and other small cavities. It consists of cells joined by small amounts of cementing substances. Epithelium is classified into types on the basis of the number of layers deep and the shape of the superficial cells. [EU] Esophagitis: Inflammation, acute or chronic, of the esophagus caused by bacteria, chemicals, or trauma. [NIH] Excitation: An act of irritation or stimulation or of responding to a stimulus; the addition of energy, as the excitation of a molecule by absorption of photons. [EU]
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Famotidine: A competitive histamine H2-receptor antagonist. Its main pharmacodynamic effect is the inhibition of gastric secretion. [NIH] Fatal: Causing death, deadly; mortal; lethal. [EU] Fats: One of the three main classes of foods and a source of energy in the body. Fats help the body use some vitamins and keep the skin healthy. They also serve as energy stores for the body. In food, there are two types of fats: saturated and unsaturated. [NIH] Fibrosis: The formation of fibrous tissue; fibroid or fibrous degeneration [EU] Fistula: An abnormal passage or communication, usually between two internal organs, or leading from an internal organ to the surface of the body; frequently designated according to the organs or parts with which it communicates, as anovaginal, brochocutaneous, hepatopleural, pulmonoperitoneal, rectovaginal, urethrovaginal, and the like. Such passages are frequently created experimentally for the purpose of obtaining body secretions for physiologic study. [EU] Fluorescence: The property of emitting radiation while being irradiated. The radiation emitted is usually of longer wavelength than that incident or absorbed, e.g., a substance can be irradiated with invisible radiation and emit visible light. X-ray fluorescence is used in diagnosis. [NIH] Gastric Acid: Hydrochloric acid present in gastric juice. [NIH] Gastritis: Inflammation of the stomach. [EU] Gastrointestinal: Pertaining to or communicating with the stomach and intestine, as a gastrointestinal fistula. [EU] Gastroscopy: Endoscopic examination, therapy or surgery of the interior of the stomach. [NIH] Glycopyrrolate: A muscarinic antagonist used as an antispasmodic, in some disorders of the gastrointestinal tract, and to reduce salivation with some anesthetics. [NIH] Halitosis: An offensive, foul breath odor resulting from a variety of causes such as poor oral hygiene, dental or oral infections, or the ingestion of certain foods. [NIH] Heartburn: Substernal pain or burning sensation, usually associated with regurgitation of gastric juice into the esophagus. [NIH] Hematology: A subspecialty of internal medicine concerned with morphology, physiology, and pathology of the blood and blood-forming tissues. [NIH] Hemorrhage: Bleeding or escape of blood from a vessel. [NIH] Hepatic: Pertaining to the liver. [EU] Hernia: (he protrusion of a loop or knuckle of an organ or tissue through an
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abnormal opening. [EU] Hoarseness: An unnaturally deep or rough quality of voice. [NIH] Homogeneous: Consisting of or composed of similar elements or ingredients; of a uniform quality throughout. [EU] Hybridization: The genetic process of crossbreeding to produce a hybrid. Hybrid nucleic acids can be formed by nucleic acid hybridization of DNA and RNA molecules. Protein hybridization allows for hybrid proteins to be formed from polypeptide chains. [NIH] Inflammation: A pathological process characterized by injury or destruction of tissues caused by a variety of cytologic and chemical reactions. It is usually manifested by typical signs of pain, heat, redness, swelling, and loss of function. [NIH] Intestinal: Pertaining to the intestine. [EU] Invasive: 1. having the quality of invasiveness. 2. involving puncture or incision of the skin or insertion of an instrument or foreign material into the body; said of diagnostic techniques. [EU] Iodine: A nonmetallic element of the halogen group that is represented by the atomic symbol I, atomic number 53, and atomic weight of 126.90. It is a nutritionally essential element, especially important in thyroid hormone synthesis. In solution, it has anti-infective properties and is used topically. [NIH]
Laparoscopy: Examination, therapy or surgery of the abdomen's interior by means of a laparoscope. [NIH] Larynx: An irregularly shaped, musculocartilaginous tubular structure, lined with mucous membrane, located at the top of the trachea and below the root of the tongue and the hyoid bone. It is the essential sphincter guarding the entrance into the trachea and functioning secondarily as the organ of voice. [NIH] Lesion: Any pathological or traumatic discontinuity of tissue or loss of function of a part. [EU] Ligament: A band of fibrous tissue that connects bones or cartilages, serving to support and strengthen joints. [EU] Lobe: A more or less well-defined portion of any organ, especially of the brain, lungs, and glands. Lobes are demarcated by fissures, sulci, connective tissue, and by their shape. [EU] Malabsorption: Impaired intestinal absorption of nutrients. [EU] Mediate: Indirect; accomplished by the aid of an intervening medium. [EU] Melena: 1. the passage of dark, pitchy, and grumous stools stained with blood pigments or with altered blood. 2. black vomit. [EU]
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Metaplasia: The change in the type of adult cells in a tissue to a form which is not formal for that tissue. [EU] Micronutrients: Essential dietary elements or organic compounds that are required in only small quantities for normal physiologic processes to occur. [NIH]
Molecular: Of, pertaining to, or composed of molecules : a very small mass of matter. [EU] Monotherapy: A therapy which uses only one drug. [EU] Motility: The ability to move spontaneously. [EU] Nausea: An unpleasant sensation, vaguely referred to the epigastrium and abdomen, and often culminating in vomiting. [EU] Necrosis: The sum of the morphological changes indicative of cell death and caused by the progressive degradative action of enzymes; it may affect groups of cells or part of a structure or an organ. [EU] Neoplastic: Pertaining to or like a neoplasm (= any new and abnormal growth); pertaining to neoplasia (= the formation of a neoplasm). [EU] Neural: 1. pertaining to a nerve or to the nerves. 2. situated in the region of the spinal axis, as the neutral arch. [EU] Neurologic: Pertaining to neurology or to the nervous system. [EU] Niacin: Water-soluble vitamin of the B complex occurring in various animal and plant tissues. Required by the body for the formation of coenzymes NAD and NADP. Has pellagra-curative, vasodilating, and antilipemic properties. [NIH] Nitrosamines: A class of compounds that contain a -NH2 and a -NO radical. Many members of this group have carcinogenic and mutagenic properties. [NIH]
Nizatidine: A histamine H2 receptor antagonist with low toxicity that inhibits gastric acid secretion. The drug is used for the treatment of duodenal ulcers. [NIH] Oral: Pertaining to the mouth, taken through or applied in the mouth, as an oral medication or an oral thermometer. [EU] Overdose: 1. to administer an excessive dose. 2. an excessive dose. [EU] Pancreatitis: Inflammation (pain, tenderness) of the pancreas; it can make the pancreas stop working. It is caused by drinking too much alcohol, by disease in the gallbladder, or by a virus. [NIH] Pediatrics: A medical specialty concerned with maintaining health and providing medical care to children from birth to adolescence. [NIH] Peptic: Pertaining to pepsin or to digestion; related to the action of gastric juices. [EU]
Glossary 165
Perforation: 1. the act of boring or piercing through a part. 2. a hole made through a part or substance. [EU] Peristalsis: The wormlike movement by which the alimentary canal or other tubular organs provided with both longitudinal and circular muscle fibres propel their contents. It consists of a wave of contraction passing along the tube for variable distances. [EU] Pharmacist: A person trained to prepare and distribute medicines and to give information about them. [NIH] Pharmacologic: Pertaining to pharmacology or to the properties and reactions of drugs. [EU] Phenotype: The outward appearance of the individual. It is the product of interactions between genes and between the genotype and the environment. This includes the killer phenotype, characteristic of yeasts. [NIH] Physiologic: Normal; not pathologic; characteristic of or conforming to the normal functioning or state of the body or a tissue or organ; physiological. [EU]
Pigmentation: 1. the deposition of colouring matter; the coloration or discoloration of a part by pigment. 2. coloration, especially abnormally increased coloration, by melanin. [EU] Postoperative: Occurring after a surgical operation. [EU] Potassium: An element that is in the alkali group of metals. It has an atomic symbol K, atomic number 19, and atomic weight 39.10. It is the chief cation in the intracellular fluid of muscle and other cells. Potassium ion is a strong electrolyte and it plays a significant role in the regulation of fluid volume and maintenance of the water-electrolyte balance. [NIH] Precursor: Something that precedes. In biological processes, a substance from which another, usually more active or mature substance is formed. In clinical medicine, a sign or symptom that heralds another. [EU] Preoperative: Preceding an operation. [EU] Prevalence: The number of people in a given group or population who are reported to have a disease. [NIH] Proximal: Nearest; closer to any point of reference; opposed to distal. [EU] Reactivation: The restoration of activity to something that has been inactivated. [EU] Receptor: 1. a molecular structure within a cell or on the surface characterized by (1) selective binding of a specific substance and (2) a specific physiologic effect that accompanies the binding, e.g., cell-surface receptors for peptide hormones, neurotransmitters, antigens, complement fragments, and immunoglobulins and cytoplasmic receptors for steroid hormones. 2. a sensory nerve terminal that responds to stimuli of various
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kinds. [EU] Recurrence: The return of a sign, symptom, or disease after a remission. [NIH] Reflux: A backward or return flow. [EU] Regurgitation: A backward flowing, as the casting up of undigested food, or the backward flowing of blood into the heart, or between the chambers of the heart when a valve is incompetent. [EU] Resection: Excision of a portion or all of an organ or other structure. [EU] Respiratory: Pertaining to respiration. [EU] Riboflavin: Nutritional factor found in milk, eggs, malted barley, liver, kidney, heart, and leafy vegetables. The richest natural source is yeast. It occurs in the free form only in the retina of the eye, in whey, and in urine; its principal forms in tissues and cells are as FMN and FAD. [NIH] Secretion: 1. the process of elaborating a specific product as a result of the activity of a gland; this activity may range from separating a specific substance of the blood to the elaboration of a new chemical substance. 2. any substance produced by secretion. [EU] Selenium: An element with the atomic symbol Se, atomic number 34, and atomic weight 78.96. It is an essential micronutrient for mammals and other animals but is toxic in large amounts. Selenium protects intracellular structures against oxidative damage. It is an essential component of glutathione peroxidase. [NIH] Serum: The clear portion of any body fluid; the clear fluid moistening serous membranes. 2. blood serum; the clear liquid that separates from blood on clotting. 3. immune serum; blood serum from an immunized animal used for passive immunization; an antiserum; antitoxin, or antivenin. [EU] Sialorrhea: Increased salivary flow. [NIH] Spectrum: A charted band of wavelengths of electromagnetic vibrations obtained by refraction and diffraction. By extension, a measurable range of activity, such as the range of bacteria affected by an antibiotic (antibacterial s.) or the complete range of manifestations of a disease. [EU] Sphincter: A ringlike band of muscle fibres that constricts a passage or closes a natural orifice; called also musculus sphincter. [EU] Squamous: Scaly, or platelike. [EU] Stomach: An organ of digestion situated in the left upper quadrant of the abdomen between the termination of the esophagus and the beginning of the duodenum. [NIH] Sucralfate: A basic aluminum complex of sulfated sucrose. It is advocated in the therapy of peptic, duodenal, and prepyloric ulcers, gastritis, reflux esophagitis, and other gastrointestinal irritations. It acts primarily at the
Glossary 167
ulcer site, where it has cytoprotective, pepsinostatic, antacid, and bile acidbinding properties. The drug is only slightly absorbed by the digestive mucosa, which explains the absence of systemic effects and toxicity. [NIH] Symptomatic: 1. pertaining to or of the nature of a symptom. 2. indicative (of a particular disease or disorder). 3. exhibiting the symptoms of a particular disease but having a different cause. 4. directed at the allying of symptoms, as symptomatic treatment. [EU] Telomerase: Essential ribonucleoprotein reverse transcriptase that adds telomeric DNA to the ends of eukaryotic chromosomes. Telomerase appears to be repressed in normal human somatic tissues but reactivated in cancer, and thus may be necessary for malignant transformation. EC 2.7.7.-. [NIH] Telomere: A terminal section of a chromosome which has a specialized structure and which is involved in chromosomal replication and stability. Its length is believed to be a few hundred base pairs. [NIH] Thermoregulation: Heat regulation. [EU] Thyroxine: An amino acid of the thyroid gland which exerts a stimulating effect on thyroid metabolism. [NIH] Toxicology: The science concerned with the detection, chemical composition, and pharmacologic action of toxic substances or poisons and the treatment and prevention of toxic manifestations. [NIH] Trachea: The cartilaginous and membranous tube descending from the larynx and branching into the right and left main bronchi. [NIH] Ultrasonography: The visualization of deep structures of the body by recording the reflections of echoes of pulses of ultrasonic waves directed into the tissues. Use of ultrasound for imaging or diagnostic purposes employs frequencies ranging from 1.6 to 10 megahertz. [NIH] Urology: A surgical specialty concerned with the study, diagnosis, and treatment of diseases of the urinary tract in both sexes and the genital tract in the male. It includes the specialty of andrology which addresses both male genital diseases and male infertility. [NIH] Varicella: Chicken pox. [EU] Vascular: Pertaining to blood vessels or indicative of a copious blood supply. [EU] Virulence: The degree of pathogenicity within a group or species of microorganisms or viruses as indicated by case fatality rates and/or the ability of the organism to invade the tissues of the host. [NIH] Xerostomia: Dryness of the mouth from salivary gland dysfunction, as in Sjögren's syndrome. [EU]
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General Dictionaries and Glossaries While the above glossary is essentially complete, the dictionaries listed here cover virtually all aspects of medicine, from basic words and phrases to more advanced terms (sorted alphabetically by title; hyperlinks provide rankings, information and reviews at Amazon.com): ·
Dictionary of Medical Acronymns & Abbreviations by Stanley Jablonski (Editor), Paperback, 4th edition (2001), Lippincott Williams & Wilkins Publishers, ISBN: 1560534605, http://www.amazon.com/exec/obidos/ASIN/1560534605/icongroupinterna
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Dictionary of Medical Terms : For the Nonmedical Person (Dictionary of Medical Terms for the Nonmedical Person, Ed 4) by Mikel A. Rothenberg, M.D, et al, Paperback - 544 pages, 4th edition (2000), Barrons Educational Series, ISBN: 0764112015, http://www.amazon.com/exec/obidos/ASIN/0764112015/icongroupinterna
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A Dictionary of the History of Medicine by A. Sebastian, CD-Rom edition (2001), CRC Press-Parthenon Publishers, ISBN: 185070368X, http://www.amazon.com/exec/obidos/ASIN/185070368X/icongroupinterna
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Dorland’s Illustrated Medical Dictionary (Standard Version) by Dorland, et al, Hardcover - 2088 pages, 29th edition (2000), W B Saunders Co, ISBN: 0721662544, http://www.amazon.com/exec/obidos/ASIN/0721662544/icongroupinterna
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Dorland’s Electronic Medical Dictionary by Dorland, et al, Software, 29th Book & CD-Rom edition (2000), Harcourt Health Sciences, ISBN: 0721694934, http://www.amazon.com/exec/obidos/ASIN/0721694934/icongroupinterna
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Dorland’s Pocket Medical Dictionary (Dorland’s Pocket Medical Dictionary, 26th Ed) Hardcover - 912 pages, 26th edition (2001), W B Saunders Co, ISBN: 0721682812, http://www.amazon.com/exec/obidos/ASIN/0721682812/icongroupinterna /103-4193558-7304618
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Melloni’s Illustrated Medical Dictionary (Melloni’s Illustrated Medical Dictionary, 4th Ed) by Melloni, Hardcover, 4th edition (2001), CRC PressParthenon Publishers, ISBN: 85070094X, http://www.amazon.com/exec/obidos/ASIN/85070094X/icongroupinterna
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Stedman’s Electronic Medical Dictionary Version 5.0 (CD-ROM for Windows and Macintosh, Individual) by Stedmans, CD-ROM edition (2000), Lippincott Williams & Wilkins Publishers, ISBN: 0781726328, http://www.amazon.com/exec/obidos/ASIN/0781726328/icongroupinterna
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Stedman’s Medical Dictionary by Thomas Lathrop Stedman, Hardcover 2098 pages, 27th edition (2000), Lippincott, Williams & Wilkins, ISBN: 068340007X, http://www.amazon.com/exec/obidos/ASIN/068340007X/icongroupinterna
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Tabers Cyclopedic Medical Dictionary (Thumb Index) by Donald Venes (Editor), et al, Hardcover - 2439 pages, 19th edition (2001), F A Davis Co, ISBN: 0803606540, http://www.amazon.com/exec/obidos/ASIN/0803606540/icongroupinterna
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INDEX A Adenocarcinoma.....40, 41, 42, 43, 44, 45, 49, 51, 53, 61, 119 Algorithms..............................................47 Alimentary......................................77, 165 Antibiotic ..................................16, 67, 166 Artery ...............................................75, 76 Aspiration...............................................18 Asymptomatic ..................................44, 65 B Bacteria ...................15, 16, 124, 161, 166 Barium .............................................38, 81 Bile.........................................52, 112, 167 Biopsy......................11, 39, 47, 48, 50, 52 C Capsules..............................................127 Carbohydrate.......................................126 Carcinogenic............................49, 57, 164 Cardia ..............................................40, 48 Cardiac ..................................................63 Catheter .................................................80 Cervical..................................................67 Chemotherapy .......................................68 Cholesterol ..................................124, 126 Chromosomal ....................41, 45, 57, 167 Chronic .11, 15, 42, 47, 51, 67, 68, 80, 87, 92, 144, 161 Cimetidine........................11, 87, 129, 131 Coagulation ...........................................83 Colitis ...............................................51, 67 Colonoscopy..............................51, 80, 81 Colorectal ..............................................51 Crowding ...............................................51 D Degenerative .......................................125 Dermatitis ..............................................67 Diarrhea.........................................66, 124 Diverticulum.....................................63, 75 Dysphagia..................................38, 66, 67 Dysplasia .....42, 46, 51, 53, 75, 81, 82, 97 E Ectopic ...................................................63 Electrolyte....................................134, 165 Endoscopy..11, 42, 44, 46, 47, 50, 52, 68, 76, 80, 87 Enteritis..................................................67 Epidemic................................................42 Epidemiological .....................................44 Epithelium............................39, 46, 47, 53 Esophagitis ...4, 11, 13, 38, 45, 65, 66, 67, 68, 87, 112, 129, 130, 131, 166
Excitation ................................ 51, 56, 161 F Famotidine ...................................... 11, 87 Fatal ................................................ 41, 51 Fats ....................... 55, 124, 133, 160, 162 Fibrosis ................................................. 68 Fistula ............................... 56, 66, 76, 162 Fluorescence .................... 46, 50, 56, 162 G Gastric Acid..................... 15, 88, 160, 164 Gastritis........................... 65, 66, 112, 166 Gastrointestinal .... 46, 47, 50, 56, 61, 62, 63, 64, 65, 66, 67, 74, 76, 92, 112, 162, 166 Gastroscopy.......................................... 51 H Halitosis ................................................ 67 Heartburn ........................ 4, 11, 38, 47, 87 Hematology........................................... 10 Hemorrhage .......................................... 65 Hepatic............................................ 49, 75 Hernia ....................... 4, 66, 67, 68, 82, 83 Hoarseness........................................... 87 Homogeneous ...................................... 43 Hybridization ......................................... 41 I Inflammation ..................... 11, 70, 87, 161 Intestinal........ 40, 61, 70, 83, 92, 124, 163 L Laparoscopy ......................................... 38 Larynx ..................................... 63, 71, 167 Lesion ....................................... 42, 49, 65 Lethal ............................................ 42, 162 Ligament ............................................... 65 M Malabsorption ................................. 66, 96 Mediate ................................................. 41 Metaplasia........................... 40, 48, 52, 83 Micronutrients ....................................... 66 Molecular . 10, 16, 44, 55, 90, 94, 95, 119, 165 Monotherapy ....................................... 129 Motility....................................... 61, 66, 92 N Nausea.................................................. 87 Necrosis ................................................ 53 Neoplastic ................................. 41, 43, 48 Neural ................................................. 125 Neurologic............................................. 68 Niacin .................................................. 125 Nitrosamines ......................................... 52
Index 171
Nizatidine...............................................87 O Oral ......38, 57, 67, 70, 133, 160, 162, 164 Overdose .............................................125 P Pancreatitis............................................67 Peptic.........65, 66, 67, 112, 129, 131, 166 Perforation .............................................66 Peristalsis ..............................................74 Pharmacist...................................106, 110 Pharmacologic...............................16, 167 Phenotype .....................................57, 165 Physiologic ........16, 64, 70, 162, 164, 165 Pigmentation..........................................67 Potassium............................................126 Precursor ...................................41, 45, 49 Preoperative ..........................................38 Prevalence.....................44, 45, 48, 52, 68 Proximal.................................................65 R Reactivation...........................................41 Receptor ..............11, 16, 68, 88, 162, 164 Recurrence ......................................28, 74 Reflux .....4, 11, 13, 18, 38, 39, 42, 44, 45, 47, 48, 51, 64, 66, 67, 68, 75, 80, 83, 87, 92, 112, 129, 130, 131, 166 Regurgitation .....................16, 38, 64, 162 Resection...................................46, 50, 74 Respiratory ......................................18, 65 Riboflavin.............................................124
S Secretion...... 15, 16, 66, 71, 88, 160, 162, 164, 166 Selenium ....................................... 52, 126 Serum ..................................... 52, 57, 166 Sialorrhea.............................................. 67 Spectrum............................................... 10 Sphincter............. 68, 70, 71, 87, 163, 166 Squamous..................... 11, 39, 47, 53, 83 Stomach..... 11, 12, 18, 47, 50, 55, 56, 63, 67, 87, 160, 162 Sucralfate............................ 129, 130, 131 Symptomatic ............... 38, 44, 45, 57, 167 T Telomerase........................................... 41 Telomere............................................... 41 Thermoregulation................................ 124 Thyroxine ............................................ 126 Toxicology....................................... 10, 91 Trachea................................... 63, 70, 163 U Ultrasonography ................................... 46 Urology.................................................. 10 V Varicella ................................................ 84 Vascular ................................................ 65 Virulence ............................................... 43 X Xerostomia............................................ 67
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